Form Center

2. The undersigned hereby makes (make) application for the issuance of a City License to operate a HOTEL or MOTEL within the corporate limits of the City of Carbondale, Illinois in accordance with Title 5, Chapter 16 of the Carbondale Revised Code.
4. Business Name*
5. Date*
7. Business Address*
8. Phone*
10. Legal Description
12. LICENSEE INFORMATION *
14. Licensee Name*
15. Email
17. Address*
19. City*
20. State*
21. Zip Code*
23. Home/Cell*
24. Fax
26. OPERATOR INFORMATION *
28. Operator Name*
29. Email
31. Address*
33. City*
34. State*
35. Zip Code*
37. Home/Cell*
38. Fax
40. PROPERTY OWNER INFORMATION *
42. Property Owner's Name*
43. Email
45. Address*
47. City*
48. State*
49. Zip Code*
51. Home/Cell *
52. Fax
54. 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)
56. Number of Rooms*
57. Number of Accessible Rooms*
58. Number of Beds*
59. Number of Roll Away Beds*
61. 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 agree.
63. Electronic Signature
65. 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.
67. Electronic Signature
68. Applicant is *

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


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field