Applicant Name *

First Name

Last Name

Applicant Phone *

(###)

###

####

Tattoo Location(s)

Select all that apply

Head / Face

Neck

Hands

Body / Other

May we share your story? *

Yes, absolutely!

Yes, but anonymously.

No

Application Endorser *

Please provide the name of someone who can endorse your application (that is not a family member or friend). This can be a counselor / therapist, attorney, case worker, social worker, community service coordinator, organization leader, halfway house representative, ministry coordinator / clergy member, reentry officer, or parole officer.

First Name

Last Name

Acknowlegement *

I acknowledge that the free treatments are intended to remove tattoos. I am also aware that tattoo removal is a journey that calls for multiple sessions. I agree to being required to arrive on time for every appointment. I understand that failure to cancel or reschedule any appointment without a minimum of 24 hours notice will result in dismissal from the program.

I acknowledge, understand, and agree.