Environmental Health Riveter Class

BCHD Announces Our Safe Body Piercing Practices Training At The Broward County Health Department Main Campus Auditorium
Your Online Registration Date Will Be: 10/8/2008
!! All Text Boxes Marked With An Asterisk Are Required !!
!! Please Do Not Use Abbreviations For The City Name !!
Your Application Number:
Please Complete This Form Using IE 4.0 or Greater, Thank You
!! Your Personal Registration Information !!
* First Name:
* Last Name:
Nick Name:	(If Applicable)
!! Your Nick Name Will Appear On Your Certificate !! Example: Icabod (The Rivet Man) Jones
* Date of Birth:
* Address:
* City:	(Change If Necessary)
* State:
* Zip Code:
County:	(Florida Applicants Only)
* Phone Number:
!! Change Area Codes If Necessary !!
Cell Number:	(If Applicable)
E-Mail Address:	@
Your Experience And Training History
Experience in Body Piercing:	Years	Months
Have You Attended A Training Class On
Infection Control and Universal Practices?
If Yes, Date Taken Month Year (If Known)
List Any Other Formal Body Piercing Training Below

If You Currently Work At A Body Piercing Salon Or You Are The Owner/Manager Of A Body Piercing Salon Please Provide The Salon Information Below
Salon Name:
Salon Address:
Salon City:	(Change If Necessary)
State:	Zip:
Owner/Manager of Salon:
Salon Phone #:
Salon FAX #:
!! Change The Area Codes If Necessary !!
Please Check ALL Of The Information Before Submitting You Can Not Make Corrections Once The Data Is Submitted
All Data Submitted Will Be Used Only By The Florida Department Of Health And The Broward County Health Department And The Information Will Not Be Sold Or Distributed To A Third Party
!!!! Only ONE Registration Application Will Be Accepted Per Applicant !!!!!