Page 2 of 2
Rev 09/14/2020
Seizures, epilepsy
Vertigo or dizziness
Eye disorders or impaired vision
If yes, do you wear corrective lenses?
Loss of hearing
If yes, do you wear a hearing aid?
Known heart condition including heart disease heart attack , or other cardiovascular condition
Addicted to drugs of abuse or alcohol
Known medical or mental condition that effects infirmity
By signing this application, the applicant acknowledges that he/she if free of any disease, condition,
infirmity, or addiction that might render the applicant unable to safety operate a motor vehicle or
otherwise pose a risk to public health and safety.
Please be advised this section is voluntarily optional and exists for the convenience of the applicant:
The applicant expressly authorizes the License Section of the City of Columbus, Department of Public Safety to obtain the current
unofficial driver abstract of the applicant via the Ohio BMV website in relation to the Vehicle for Hire Driver license for which application
is
being made. Any information provided will be held in strict confidence at all times and shall not be disclosed to any other department
or division of the City of Columbus, nor used for any other purpose other than as stated.
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 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
Yes
No
Last four digits of SSN
