Page 2 of 2
Rev 9/14/2020
City: State: Zip:
Phone: Email:
Legal Owner of Property:
Property Control Agreement (If yes, submit copy):
N
o
Property Owner Address:
City: State: Zip:
Phone: Email:
Other Properties? Yes
No Names/Locations:
If Corporation, List Agent/Managing Individual: State of Registration:
Agent/
Managing Individual Address:
City: State: Zip:
Phone: Email:
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 CHAPTERS 501
AND 540 IN THE COLUMBUS CITY CODE.
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.
Yes
