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Rental Housing Registration and Designation of Agent

  1. The purpose of this filing is: (Select all that apply)*
  2. OWNERSHIP INFORMATION
  3. Ownership: (Select one)*
  4. PROPERTY INFORMATION
  5. AGENT INFORMATION
    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.
  6. Is the agent the owner?*
  7. Affirmation*
    By checking the "I affirm" box below, you affirm that the information herein is correct and hereby designate the above named Agent to receive notices concerning the listed property(ies). The Agent of his/her designee is also authorized to grant the City of Carbondale access to the interior and exterior of the listed propoerty(ies) for the purpose of conducting housing inspections pursuant to Section 4-4-16-D of the Carbondale Revised Code.
  8. Acknowledgment*
    By checking the "I agree" box below, you acknowledge that you are the agent for the above owner for the herein listed property(ies) and agree 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 Carbondale Revised Code.
  9. 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.
  10. Leave This Blank:

  11. This field is not part of the form submission.