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If yes, please explain:
Does this facility conform to all City Codes, including, but not limited to, Zoning, Building, Health, and Fire?
Yes No
List all persons who will be directly engaged in managing or supervising daily operations of said facility:
(If your list exceeds the space available, please attach a document to the application.)
1. Full Name: Title:
Date of Birth: Driver License #: State:
Residential Address:
City: State: Zip:
2. Full Name: Title:
Date of Birth: Driver License #: State:
Residential Address:
City: State: Zip:
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
