Revised 3/23/2016 Page - 1 - of 2
LICENSE # _______________________
ISSUE DATE______________________
EXPIRES ________________________
Business Name: Federal ID:
Check One: Sole Proprietor Corporation Partnership LLC
Business Address:
City: State: Zip Code:
Phone Number: Cell Phone:
Email:
Full Name:
Date of Birth: Email:
Current Address:
City: State: Zip Code:
Phone Number: Cell Phone:
Ohio Driver’s License Number: Expiration Date:
Sex: M F
R
ace:
Hei
ght:
We
ight:
H
air:
E
yes:
Are you legally authorized to work in the United States? YES NO
All applicants will be required to prove Lawful Presence in the United States and provide
Proof of Identity.
Have you had a City of Columbus license and/or permit revoked, suspended or refused within the last three (3) years?
YES NO If yes, please explain:
Have you ever been convicted of a felony? YES NO
List all felony convictions in the United States over the past seven (7) years. If none, write “NONE”.
Are you on felony probation or parole? YES NO
If yes, date began:
Have you ever been required to register as a sexual offender? YES NO
If yes, date began:
DEPARTMENT OF PUBLIC SAFETY
LICENSE SECTION
CARRIAGE-(HORSE)
LICENSE
APPLICATION
NEW RENEWAL
