This form contains 58 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Accounts Receivable Address
Accounts Receivable In Care Of	Text	Please provide the name of the billing office or person in charge for the accounts receivable address.
Accounts Receivable Billing Address	Text	Please provide the primary billing street address for accounts receivable.
Accounts Receivable City/State/Zip Code	Text	Please provide the city, state, and zip code for the accounts receivable address.
Accounts Receivable Phone Number	Text	Please provide the phone number for the accounts receivable contact.
Accounts Receivable Fax Number	Text	Please provide the fax number for the accounts receivable contact.
Annual Packets Mailing Preference
Annual Packets Mailing Preference - Yes	Checkbox	Check this box if you would like annual packets mailed to the provided address and will skip Part B.
Annual Packets Mailing Preference - No	Checkbox	Check this box if you do not want annual packets mailed to the provided address and will complete Part B.
Body Art Facility Information
Facility Name	Text	Please enter the full name of the body art facility.
Health Permit PR Number	Text	Please provide the health permit PR number for the facility.
Facility Address	Text	Please enter the street address of the body art facility.
Facility City	Text	Please enter the city where the body art facility is located.
Facility Zip Code	Text	Please enter the zip code of the body art facility.
Facility Phone	Text	Please enter the phone number for the body art facility.
Facility Email	Text	Please enter the email address for the body art facility.
Body Art Practitioner Information
Practitioner Name	Text	Please enter the full name of the body art practitioner.
Registration Number	Text	Please enter the practitioner's registration number.
Practitioner Mailing Address	Text	Please provide the complete mailing address for the practitioner.
City	Text	Please enter the city of the practitioner's mailing address.
Zip Code	Text	Please enter the zip code of the practitioner's mailing address.
Phone	Text	Please provide the practitioner's contact phone number.
Email	Text	Please enter the practitioner's email address.
First Facility Information
FACILITY NAME	Text
ADDRESS	Text
CITY, ZIP CODE	Text
PHONE	Text
General
Permit Owner Signature	Signature
Signature of Applicant	Signature
Information Update
Practitioner Address	Checkbox	Check this box if you are providing an update to the practitioner's address.
Accounts Receivable	Checkbox	Check this box if you are providing an update to accounts receivable information.
Facility	Checkbox	Check this box if you are providing an update to the facility information.
New Application For
New Application for Tattooing	Checkbox	Check this box if you are submitting a new application for Tattooing.
New Application for Piercing	Checkbox	Check this box if you are submitting a new application for Piercing.
New Application for Permanent Cosmetics	Checkbox	Check this box if you are submitting a new application for Permanent Cosmetics.
New Application for Branding	Checkbox	Check this box if you are submitting a new application for Branding.
Page 3
Applicant Name	Text	Enter the full name of the applicant as it should be printed.
Signature Date	Date	Provide the date the application was signed.
Permit Owner Details
Permit Owner Name (Print)	Text	Enter the printed full name of the permit owner.
Permit Owner Signature Date	Date	Provide the date the permit owner signed the agreement.
Practitioner Physical Address
Practitioner Name	Text	Enter the full name of the practitioner as it appears on their Driver's License or Federal Tax ID.
Practitioner Home Address	Text	Enter the full home address of the practitioner.
City, State, Zip Code	Text	Enter the city, state, and zip code for the practitioner's home address.
Phone Number	Text	Enter the practitioner's phone number.
Fax Number	Text	Enter the practitioner's fax number.
Email Address	Text	Enter the practitioner's email address, which will be used for recall notices, renewal applications, and newsletters.
Renewal For
Renewal Tattooing	Checkbox	Check this box if you are renewing your tattooing practitioner application.
Renewal Piercing	Checkbox	Check this box if you are renewing your piercing practitioner application.
Renewal Permanent Cosmetics	Checkbox	Check this box if you are renewing your permanent cosmetics practitioner application.
Renewal Branding	Checkbox	Check this box if you are renewing your branding practitioner application.
Second Facility Information
Second Facility Name	Text	Enter the name of the second facility where you currently operate or plan to engage in tattooing, body piercing, branding, or permanent cosmetics.
Second Facility Address	Text	Provide the street address for the second facility.
Second Facility City, Zip Code	Text	Enter the city and zip code for the second facility.
Second Facility Phone Number	Text	Provide the phone number for the second facility.
Submission Requirements
Completed Body Arts Practitioner Application form with signature and Location of Operation Agreement	CheckBox
A copy of your current Contra Costa EH Approved Bloodborne Pathogen Certificate of Training	CheckBox
Proof of Hepatitis B vaccination or a Hepatitis B declinationform	CheckBox
Copy of ID-Proof practitioner is over age 18	CheckBox
Registration fee of $150.00. Fees are subject to change. Please see the current feeschedule	CheckBox
45.00 non-refundable application fee required for new applicants	CheckBox

Contra Costa Environmental Health Division Body Arts Practitioner Application Instructions