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List the name, date of birth, driver’s license number or State ID number, home address and title of all persons who
have a direct or indirect interest in the business (including partners, stockholders, lien holders and corporate officer):
Title Home Address Zip Code
Attached additional sheet(s) if necessary.
Number of Carriages to be licensed:
Number of horses to be licensed:
Location of staging area:
What rates will be charged:
List all criminal arrests and convictions within the past seven (7) years of any person having direct interest in
that which is to be licensed (If none write “NONE”):
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 OR FUTURE REVOCATION OF THIS
LICENSE, AS WELL AS CRIMINAL PROSECUTION UNDER CHAPTER 2321.13(A-3), (A-5) AND COLUMBUS CITY CODE 589.
State of Ohio, County of Franklin
_____________________________________________________, being duly sworn, deposes and says
he/she is the individual making the foregoing application; that he/she is knowledgeable with respect to that which is
to be licensed; that the answers to the foregoing questions and other statements contained herein are true of his/her
own knowledge and belief.
Swore 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