Page 2 of 2
Rev 1/8/2019
Does this establishment conform to all applicable City, State, and Federal codes and laws? (i.e. Building & Zoning, Health, and Fire)
Yes No
List all persons who have a direct or indirect interest in the business, including corporate officers that hold 10%
or more of stock offered by said corporation or partnership: (Please attach a separate list if the list exceeds the allotted spaces)
1. Full Name: Title:
Residential Address:
City: State: Zip:
Date of Birth: Driver License #: State:
2. Full Name: Title:
Residential Address:
City: State: Zip:
Date of Birth: Driver License #: State:
Per regulations set in Columbus City Code 501.05(E), the License Section has the power to make rules
regarding the “qualifications of the applicants and the conditions precedent the applicants must meet
prior to the acquisition of licenses.” Following this direction, all applicants must be able to read, speak,
and comprehend the English language in order to obtain a valid license. By initialing on the line below,
you agree that you are able to fulfill this requirement.
_______ Initials
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
I, _____________________________________, being duly sworn, affirm and swear that I am the
(Print Applicant’s Name)
individual making the foregoing application; that he or she is knowledgeable with respect to that
which is to be licensed and to the information contained in the application; that the answers,
statements, and allegations made in this application are true and accurate to the best of my
knowledge and belief; and that I am an owner/operator/applicant of that which is to be licensed by
this application.
____________________________________
(Applicant’s Signature)
Sworn to before me and subscribed in my presence this ____ day of ____________________, 20____.
________________________________
Notary or Agent of Director of Public Safety
