HomeMy WebLinkAbout229266 2/12/2014 �". CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $1,926.70
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 229266
CHECK DATE: 2/12/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4341999 00-22226 881 . 38 OTHER PROFESSIONAL FE
1110 4341999 31457 00-22226 1, 045 . 32 PHYSICALS
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
w Indianapolis, IN 46204
0 Carmel Police Department/CARMEPD
_ 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 01/29/2014
m Invoice# 00-22226
Date Employee Description Amount Balance Due
01/21/14 Stein,Amy J. PSY-Fit For DutV Psych Eval Initial $850.00 $850.00
01/24/14 Haste, Seth 0. Chart Review/Completion $88.52 $88.52
Indiana PERF Exam $198.92 $198.92
Druo Screen 9 +Opiates&Oxycodone $43.72 $43.72
Applicant Blood Panel-PERF $125.50 $125.50
Tb Skin Test $7.65 $7.65
_
Venipuncture $3.29 $3.29
Chest X-Ray-PA/LAT(Digital) 65.58 $65.58
Tonometry Glaucoma Test 39.35 $39.35
Urinalysis-Di stick $3.29 $3.29
EKG W1 Interr) $21.86 $21.86
Audiometry $15.31 $15.31
PFT-Pulmonary Function Test $36.07 $36.07
Vision-Color Ishihara $28.42 $28.42
Vision-Acuity 28.42 $28.42
Vital Signs-HT WT BP P R 0.00 $0.00
PSY-Applicant Psvch Eval 370.80 $370.80
Total Charges->1 $1,926.70
Total Payments&Balance Due-> $0.00 $1,926.70
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797
City
of
Carmel
INDIANA RETAIL TAX EXEMPT PAGE
CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPTi'I4�j7
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997 SHIPPING LABELS AND ANY CORRESPONDENCE.
'URCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
994
Public 82feiV MGdisal Sorvieeo Camel Police Department
VENDOR SHIP 3 CIVIC squm
324 E. New York Straot, SuRG 3W TO Camel, IN 46032
Indi2napoIIs, IN 4M (317)57 2574
CONFIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT
Account
QUANTITY �e UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43-499.99
9 Each physical for applicant $575.10 $075.18
1 Each psythological evaluation $370.93 $370.13
y Sub Total: $1,045.32
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Send Invoice To:
Camel Police Dep2ftmont ..y.e✓ <e
Attn: Pat Young
3 CIVIC Squam
Cannel, IN 482- PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT I PROJECT ACCOUNT AMOUNT
Cwnel Police Dept. PAYMENT M'U5'32
N A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THE-7 IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIATION OF IJE
NT TO PAY FOR THE ABOVE ORDER.
•SHIP REPAID. 7l
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED. ORDERED BY
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL
SHIPPING LABELS. of
Polleg
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO-
CLERK-TREASURER
DOCUMENT CONTROL NO. 314 5 7 A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO. WARRANT
ALLOWED 20
IN THE SUM OF$
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT•# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except.-- --- ---- - - - ---...- -- --
20 .
....................................,......-......................-_..-.._..................-...................._.............._..................--..._.........._-.
Signature
....................... ..............................................................................................
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$1,926.70
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 00-22226 43-419.99 $881.38 I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
31457 00-22226 43-419.99 $1,045.32
materials or services itemized thereon for
which charge is made were ordered and
received except
Frida , Feb
r ary 07, 2014
i
,I
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
r
f
Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
01/29/14 00-22226 Fit for duty pysch- Stein $881.38
01/29/14 00-22226 physical/psych evaluation $1,045.32
I hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance
with IC 5-11-10-1.6
20
Clerk-Treasurer