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I have requested a tattoo of: (tattoo and placement) <br />I have verified that the tattoo above is correct (name/date/drawing) and the <br />placement is in the correct area on my body. <br />If any provision, section, subsection, clause or phrase of this release is found to be <br />unenforceable or invalid, that portion shall be severed from this contract. The remainder <br />of this contract will then be construed as though the unenforceable portion had never <br />been contained in this document. <br />I hereby declare that I am 18 years of age (and have provided valid proof of age and <br />identification) and am competent to sign this Agreement. I have read and completed the <br />consent form. I am aware that this is a permanent procedure. <br />I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND <br />BY IT. <br />Signature: <br />Print: <br />Date of Birth: <br />Address: <br />City: State: <br />Form of identification: <br />