MEMORANDUM
TO: Licensees
FROM: Vanessa Beauchamp
Executive Director
Date: January 29, 2010
RE: Apprenticeships
Effective January 30, 2010, new regulations require that within ten (10) days of an
apprenticeship beginning, a supervising practitioner must register all people who are
working on fulfilling the required apprenticeship requirements under his or her
supervision.
It will be necessary that you complete the Registration of Supervisory Relationship form
for each apprentice you will be supervising. The form should be submitted to the above
address within ten (10) days of the apprenticeship commencing.
Upon completion of the apprenticeship, regulations require that an apprentice’s proof of
completion of the apprenticeship be submitted on forms prescribed by the office. The
Certification of Apprenticeship form should be used to track all hours/procedures
completed. An apprentice should return the Certification of Apprenticeship with his or
her application, all required documents, and the appropriate fee once all requirements are
met.
Please note that no license will be issued to an individual working on fulfilling the
apprenticeship requirements; the registration of supervisory relationship is merely a
registration. In addition, an individual may have more than one supervising practitioner.
However, each supervising practitioner must be registered with the Office as described
above.
If you have any questions, please contact the office at the above number.
STATE OF MISSOURI OFFICE OF TATTOOING, BODY PIERCING AND BRANDING
3605 MISSOURI BOULEVARD
DIVISION OF PROFESSIONAL REGISTRATION JEFFERSON CITY MO 65109
REGISTRATION OF SUPERVISORY RELATIONSHIP TELEPHONE: 573-526-8288
FAX: 573-526-3489
I hereby certify that I am a licensed tattooist, body piercer and/or brander meeting the required qualifications for a
supervisor as promulgated by the Division of Professional Registration/Office of Tattooing, Body Piercing and Branding in
20 CSR 2267-2.010(1)(c). I agree to supervise the practitioner named on this form. I understand that I am responsible for
the training, guidance and direct supervision of the practitioner as outlined in 20 CSR 2267-2.010(1)(c). I further understand
that I am to notify the Office within ten (10) days of termination of the supervisory relationship.
SUPERVISOR NAME (TYPED OR PRINTED) SUPERVISOR LICENSE NUMBER
NAME OF ESTABLISHMENT EMAIL
ESTABLISHMENT ADDRESS (STREET, CITY, STATE, ZIP CODE)
SUPERVISOR’S SOCIAL SECURITY NUMBER TYPE OF APPRENTICESHIP (TATTOOING, ESTABLISHMENT LICENSE NUMBER
BODY PIERCING AND/OR BRANDING)
SUPERVISOR’S SIGNATURE DATE
NOTARY PUBLIC EMBOSSER OR STATE COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF YEAR USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
NAME OF SUPERVISEE (FIRST, MIDDLE INITIAL, LAST - TYPED OR PRINTED) EMAIL
SUPERVISEE HOME MAILING ADDRESS (STREET, CITY, STATE, ZIP CODE) DATE OF BIRTH (MONTH/DAY/YEAR)
SUPERVISEE’S TELEPHONE NUMBER SUPERVISEE’S SOCIAL SECURITY NUMBER DATE
SUPERVISEE’S SIGNATURE
NOTARY PUBLIC EMBOSSER OR STATE COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF YEAR USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 375-0778 (10-2020)
...-.,.....
STATE OF MISSOURI Save II Print Ill Reset 7
t="
• DIVISION OF PROFESSIONAL REGISTRATION OFFICE OF TATTOOING, BODY PIERCING AND BRANDING
CERTIFICATION OF APPRENTICESHIP 3605 MISSOURI BOULEVARD
JEFFERSON CITY MO 65109
;nclude at least 300 hours w;th a m;n;mum of 50 completed procedures.
APPRENTICE NAME (PRINT) SUPERVISOR NAME (PRINT) SUPERVISOR LICENSE NO.
PATRON'S DATE OF NO.OF
PATRON'S NAME SIGNATURE OF APPRENTICE SIGNATURE OF SUPERVISOR
AGE PROCEDURE HRS. MINS.
TOTAL 0 0
MO 375-0777 (4-2022) (NOTE: PLEASE MAKE AS MANY COPIES OF FORM AS NECESSARY)
