Form Center

2. The undersigned hereby makes (make) application for the issuance of a City License to operate a Bed & Breakfast Establishment within the corporate limits of the City of Carbondale, Illinois in accordance with Title 5, Chapter 4 of the Carbondale Revised Code.
4. Business Name*
5. Date*
7. Business Address*
8. Phone*
10. LICENSEE INFORMATION *
12. Licensee Name*
13. Email*
15. Address*
17. City*
18. State*
19. Zip Code*
21. Home/Cell*
22. Fax
24. OPERATOR INFORMATION *
26. Operator Name*
27. Email
29. Address*
31. City*
32. State*
33. Zip Code*
35. Home/Cell*
36. Fax
38. PROPERTY OWNER INFORMATION *
40. Property Owner's Name*
41. Email
43. Address*
45. City*
46. State*
47. Zip Code*
49. Home/Cell *
50. Fax
52. Additional information
    * If the proposed licensee, operator or property owner is a corporation, partnership or limited liability company; the partner's, officer's or member's names and residence addresses shall be furnished. (Attach separate sheet)
53. Site Plan*
    Attach a drawing of the site showing: i) the location of all existing and proposed structures in relation to the property line, and ii) the location of all existing and proposed parking areas and driveways in relation to the property lines and structures.
54. Floor Plans*
    Attach existing and proposed floor plans of all structures on the property.
55. Insurance*
    Attach Certificate of Insurance
57. Legal description of licensed premises.*
59. Description and address of contiguous premises under the control of licensee, but not licensed.
61. This application is being made as (check one)*

    1. Corporation
    2. Partnership
    3. Individual
63. Number of Rooms*
64. Number of Accessible Rooms*
65. Number of Beds*
66. Number of Roll Away Beds*
68. Certification*

    I hereby certify that I will not violate any of the ordinances of the City of Carbondale or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein and that the statements contained in this application are true and correct to the best of my knowledge and belief.

    1. I certify.
70. Electronic Signature*
72. Electronic Signature Agreement*

    By checking the "I certify" box below, you certify (or declare) under penalty of perjury under the laws of the State of Illinois that the foregoing is true and correct.

    1. I certify.
74. Electronic Signature*
76. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
78. Electronic Signature*
79. Applicant is *

    1. Licensee
    2. Operator
    3. Property Owner
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field