* 1. Name:

* 2. Age

* 3. Date of Birth

* 4. Gender

* 5. Are you currently on Probation or Parole?

* 6. Have you ever been arrested?

* 7. What was the date of your last arrest?

* 8. If arrested, what was the charge?

* 9. Where do you have tattoos?

* 10. How many tattoos do you have on your head, neck, face and/or hands?

* 11. My tattoos are (mark all that apply)

* 12. I consider my tattoo

* 13. I got my tattoo to represent a gang or gang life?

* 14. My tattoos have kept me from (mark all that apply)

* 15. Are you employed?

* 16. Are you attending school?

* 17. Have you earned your High School Diploma or GED

* 18. How did you hear about this program?

* 19. Why is it important to you to have your tattoo(s) removed?

* 20. Phone number:

* 21. Email address:

* 22. Address:

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