ARTIST APPLICATION

    Illinois Body Art Program
    Lake County, Illinois
    Artist Information




    Legal Name of Artist/Apprentice

    *First Name: *Last Name:
    Other Name May be Known By (If Different From Above):

    *Responsibilities and/or Duties:


    *Residential Address:
    *City: *State: *Zip Code:
    *Home Telephone Number: Other Telephone:
    *Professional Email Address: Professional Website:
    *Date of Birth:




    Employment:

    *Business Name 1:

    *Title or Position:
    *Business Telephone:
    *Business Address:
    City: State: *Zip Code:





    Business Name 2:

    Title or Position:
    Business Telephone:
    Business Address:
    City: State: Zip Code:





    Business Name 3:

    Title or Position:
    Business Telephone:
    Business Address:
    City: State: Zip Code:





    TRAINING / CERTIFICATIONS

    Date of Blood Borne Pathogen Training

    *Other Trainings / Certifications:
    Other Trainings / Certifications:
    Other Trainings / Certifications:




    REQUIRED DOCUMENTATION

    *Copy of photo identification:

    *Copy(ies) of all certifications and trainings:




    BAE - Artist Information Template
    Ver. 2010.04.01

    Lake County Health Department & Community Health Center
    Lake County Illinois