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Last, First, MI
Include City, State, Zip
List names, addresses, and telephone number of partners.
List names, addresses, and telephone numbers of corporate officers and agents, and state of incorporation.
List names, addresses, and telephone numbers of trustees
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:
Last, First, MI or Company Name
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.
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.
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.
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