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Rev 06/14/2019
RENEWAL APPLICANTS ONLY, has there been any structural changes to the establishment since last year?
Yes No
If yes, please explain:
List all persons who have direct or indirect interest in said business (i.e. partners, stockholders, lien holders, etc.):
(If additional space is needed, attach on a separate sheet)
1. Name: Title: Date of Birth:
Address:
City: State: Zip:
2. Name: Title: Date of Birth:
Address:
City: State: Zip:
Please be advised this section is voluntarily optional and exists for the convenience of the applicant:
The applicant expressly authorizes the Licensing Division of the City of Columbus, Department of Public Safety to contact the Income
Tax Division of the City of Columbus - City Auditor and in turn expressly authorizes the Income Tax Division of the City of Columbus -
City Auditor to provide access to the Licensing Division of the City of Columbus, Department of Public Safety current municipal tax
information related to the applicant listed above in relation to the Short-Term Rental Permit for which application is being made. Any
information provided to the Licensing Division will be held in strict confidence at all times and shall not be disclosed to any other
department or division of the City of Columbus, nor used for any other purpose other than as stated.
All information contained in this application is subject to disclosure as a matter of public record. Any
false statement made or given in this application shall result in denial, revocation, or future revocation
of the license under Columbus City Code Chapters 501 and 540, and may be referred for criminal
prosecution under Ohio Revised Code Chapter 2921.13 (A-3).
State of Ohio, County of Franklin
_____________________________________, being duly sworn, deposes and says he or she is the
(Print Applicant’s Name)
individual making the foregoing application; that he or she is knowledgeable with respect to that which
is to be license; and that the answers to the foregoing questions and other statements contained herein
are true of his or her own knowledge and belief.
___________________________________
(Applicant’s Signature)
Sworn to before me and subscribed in my presence this _____ day of __________________, 20_____.
______________________________________
Notary or Agent of Director of Public Safety
Application must be signed, dated, and notarized.
