NIPCM - Request for Information - National Institute for Permanent Cosmetics and Micropigmentation

Name

Email

Phone

Home Address

City

State/Province

Zip/Postal

Do you have any experience as a permanent cosmetic artist?

Yes

No

How many years of permanent cosmetics experience do you have?

1-2

3-5

6-10

10+

Are you currently practicing permanent cosmetic tattooing?

Yes

No

Name of business where you are practicing

Business website

Business Address

City

State/Province

Zip/Postal

Do you have or have you ever held a permanent cosmetic practioner license?

Yes

No

State where licensed

Date license was issued

Date license expires

Do you have experience in any of these related fields?

(Select all that apply)

Do you have any other certifications (cosmetology, body tattooing, medical, or esthetics?

Yes

No

Please enter the names of certifications and dates obtained.

(Separate multiple entries with a comma)

Which areas of permanent cosmetics and micropigmentation are you most interested in?

(Choose all that apply)

Why are you interested in becoming a certified professional?

After completion of the certification program, what are your plans and goals for your career as a PCM Professional?

Tell us a little about yourself and your background.

Is there anything else you would like to share or ask?

We require proof of residency, please provide a copy of your state issued i.d.

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