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2. The purpose of this filing is:*

   1. Initial Registration
   2. Change in Property Information

   1. Change of Ownership Information
   2. Change in Agent/Agent's Information

   1. Yearly Renewal

4. OWNERSHIP INFORMATION

6. Company Name (if applicable)
8. Owner*

   Last, First, MI

9. Email
11. Mailing Address*

    Include City, State, Zip

13. Driver's License Number*
14. Issuing State*
15. DOB*
17. Home Telephone
18. Work Telephone
19. Cell Phone
21. Owner is:*

    1. Individual(s)
    2. Partnership

    1. Corporation/LLC
    2. Land Trust

    1. Estate
    2. Other (indicate below)
23. Indicate "Other"
25. Partnership

    List names, addresses, and telephone number of partners.

27. Corporation

    List names, addresses, and telephone numbers of corporate officers and agents, and state of incorporation.

29. Land Trust

    List names, addresses, and telephone numbers of trustees

31. PROPERTY INFORMATION

33. Address
34. Select which applies

    1. Residential

    1. Commercial
36. Address
37. Select which applies

    1. Residential

    1. Commercial
39. Address
40. Select wich applies

    1. Residential

    1. Commercial
42. Address
43. Select which applies

    1. Residential

    1. Commercial
45. Upload Proof of Insurance*
49. AUTHORIZED AGENT INFORMATION

    Note: Individual property owners who reside in Jackson, Union, Williamson, Randolph, Franklin, or Perry County, Illinois may designate themselves as Agent. All other owners must designate as an Agent a person who resides in one of the above-listed counties.

    If the Agent is NOT the owner, please complete the following:

51. Agent's Name

    Last, First, MI or Company Name

52. Email Address
54. Home Address

    Include City, State, Zip

55. Work Address

    Include City, State, Zip

57. Home telephone
58. Work telephone
59. Cell phone
61. Verifications

    1. The above listed property(ies) meets the definition of a "secured building" under Title 4, Chapter 16, Section 2 of the Carbondale Revised Code
    2. The above listed property(ies) meets the requirements of Title 4, Chapter 16 of the Carbondale Revised Code
    3. Proof of the required insurance is attached with this registration form and meets the requirements of Title 4, Chapter 16, Section 6 of the Carbondale Revised Code

63. The undersigned owner affirms that the information herein is correct and hereby designates the above-named Agent to receive notices concerning the listed property(ies). The Agent or his/her designee is also authorized to grant the City of Carbondale access to the interior and exterior of the listed property(ies) for the purpose of conducting housing inspections pursuant to Section 4-4-16-D Revised Code of the City of Carbondale.

65. Owner 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. Owner Electronic Signature*
68. Date*

70. The undersigned acknowledges that he/she is the agent for the above owner for the herein listed property(ies) and agrees to accept notices from the City concerning the listed property(ies) and to grant the City access to the interior and exterior of the listed property(ies) for the purpose of conducting housing inspections pursuant to Section 4-4-16-D of the Revised Code of the City of Carbondale.

72. Agent 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.
74. Agent Electronic Signature*
75. Date*
Leave This Blank:


77. Submit

* indicates a required field