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.p.r <br /> li i' c r - Permanent Cosmetics and frattooincuthfonnedons <br /> Last Name First Name Date <br /> Address <br /> street Apt.# city state ZIP <br /> Date of Birthtin on BodyName of Practitioner <br /> COPY OR DESCRIPTIONF PERMANENTC TIC OR TATTOO <br /> I accept this design or procedure. Client Signature <br /> ID ID <br /> Permanent Cosmetics and Tattooing Page 1 of <br />