Page 2 of 2
Rev 12/06/2019
RENEWAL APPLICATIONS 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 your list extends over the allotted space attach a separate list to your application)
1. Name: Title: Date of Birth:
Residential Address:
City: State: Zip:
2. Name: Title: Date of Birth:
Residential 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.
Yes No
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 THE DENIAL OF THE
APPLICATION OR FUTURE REVOCATION OF THIS LICENSE. APPLICANT MAY ALSO BE REFERRED FOR CRIMINAL
PROSECUTION.
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
Must be SIGNED, DATED, and NOTARIZED.
