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DEPARTMENT OF PUBLIC SAFETY
Taxi Company Name: Taxicab #:
City: State: Zip:
Date of Birth: Driver License #: State:
Race: Sex: Height: Weight: Hair: Eyes:
All applicants are required to provide Proof of Identity.
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 Transferee’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 of that which is to be licensed by this application.
Sworn to before me and subscribed in my presence this ______ day of _____________________, 20_____.
Notary or Agent of Director of Public Safety
Cab # _________________________________
License # ______________________________
Decal # __________ Color ________________
Issue Date _____________________________
Expiration Date __________________________