HomeMy WebLinkAbout229453 2/25/2014 CITY OF CARMEL, INDIANA VENDOR: 367252 Page 1 of 1
ONE CIVIC SQUARE E V T CERTIFICATION COMMISSION INCCHECK AMOUNT: $100.00
� o CARMEL, INDIANA 46032 Po sox 894
DUNDEE IL 60118 CHECK NUMBER: 229453
CHECK DATE: 2/25/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 100 . 00 EXTERNAL INSTRUCT FEE
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Certification Commission Inc. 'CIO W
EVTCertification Commission,Inc. Exam Registration Form
Have you ever registered for an EVr Certification exam before?Yes❑ No❑
xxx-xx-6442 317 - 417 - 0146 317 - 690 4283
Last 4 Digits of Social Security# Home Phone Work Phone
Force Jason Sprence
Last Name First Name MI
655 Birch Street
Mailing Address
Westfield 46074 iforce@carmel.in.00v
city State Country Zip or Postal Email Address
code
Date of Birth 03 1,09 '/.73 Sex: R Male❑ Female Years of education completed:1116 years.
Employer Name:;City of Carmel Fire Dept _ Which of the below list best describes your current employer?
❑ 1.Fire Department Garage❑3.Manuf.Dealer or Service❑ 5.Military❑7.Independent Service Center❑9.Other
❑ 2.Municioai Garaoe 1:14.Fle_et Service Shoo❑6.Manufacturer_❑8.-Volunteer FD or Rescue Service
DATE OF EXAM:i Saturday Apr 12, 2014 8:00 a.m. ;21-day Advance Registration Required
TESTSITE# IN41214 City,St Indianapolis,
*Note:Re-certification exams are for technicians whose certification is expiring. EVr Certification reserves the right to affirm to interested parties
-a maximum of two regular exams or six*re-certification exams gr one regular&three*re- the areas in which a techni'n is EVr 'fled.
certification exams may be taken
Regular Recertification* Applicants Signature:
$50.00 $30.002. 2 D 4
F1 ❑ Fl Insoetion.Maintenance&Testing Dale: /
F2 ❑ ❑ F-2 Fire Apparatus Design&Performance Fees:
F3 ❑ ❑ F3 Fire Pumos&Accessories Number of: v C
F4 ❑ ❑ F4 Fire Apparatus Electrical Systems Regular exams: X$50.00=$-5-e—
FA4❑ ❑ FA-0 Advanced Electrical Systems Recertification exams:_X$30.00=$
to take the FK-4'V66 must hive F4 or E2 Registration Fee:one-time fee for
F5 ❑ ❑ FS Aerial Fire Apparatus NEW registrants only 520.00=S p
dr
F6 ❑ ❑ F6 Allison Automatic Transmission '
Total Fees=$�Q
F7 ❑ ❑ F7 Foam Systems Cpnfinmation letter and a picture ID is recuired at exam site
F8 ❑ ❑ F8 Hydraulic Systems We will mail a confirmation latter within 2 business days of
EO E-0 Inspection,Maintenance&Testing receiving it If you do not receive one,please call the EVT
office immediately.
El ❑ ❑ E-1 Ambulance Design&Performance Visit us online at:www.eikT.org
E2 ❑ ❑ E-2 Ambulance Electrical Systems
E3 ❑ ❑ E-3 Ambulance HVAC
E4 ❑ ❑ EA Ambulance Body&Chassis
AT ❑ ❑ A-1 ARFF Veh_uie Desicn&Performance
A2 ❑ ❑ A-2 ARFF Chassis&Components
A3 ❑ ❑ A-3 ARFF Extincuishment Systems
Ll ❑ ❑ L-1 Law Enforcement Vehicle Installation
MI ❑ ❑ M-1 Manaqement Level I Supervisor
M2 ❑ ❑ M-2 Management Level II Supervisor
to take the M-2 you must be certified in M 1
Method of Payment:1_I Visa 1-1 Master Card 1-1 Money Order 1-1 Check#
Credit card#I_I_I—I—I I—I_I—I_I I—I—I_I_I I—I—I—I—I Security Code 1_I-1-1 Expiration Date 1-1-1
(from back of card) Month/Year
Name on credit card and billing address(if different from applicants name and mailing address)
Sicnature of credit card holder: Date:
Mail or fax this form and payment to:EVr Certification Commission,Inc.PO Box 894 Dundee,IL 60118
Febmary 1.2011 Phone:847-426-075 FAX:847-426-4076
https://register.evtcc.org/page/printreg?txt socnum=6442&txt firstname=Jason+&txt middlenam... 2/20/2014
printreg Page 1 of 1
I Certification Commission Inc. ,
EVTCertification Commission, Inc. Exam Registration Form
Have you ever registered for an EVr Certification exam before?Yes❑No❑
xxx-xx-7153 317 - 758 6418 317 - 664 0958
Last 4 Digits of Social Security# Home Phone Work Phone
VanVoorst Robert Joseph
Last Name First Name MI
23402 Mule Barn Rd.
Mailing Address
Sheridan 46069 bvanvoorst@carmel.in.aov
City State Country Zip or Postal Email Address
Cnr1e
Date of Birth 08_/ 28 / 57 Sex: Male❑Female Years of education completed:1 12 years.
Employer Name:'City of Carmel Fire Dept 'Which of the below list best describes your current employer?
❑ 1.Fire Department Garage❑3.Manuf.Dealer or Service❑5.Military❑ 7.Independent Service Center❑9.Other
❑2.Municipal Garage El4.fleet Service Shoo❑6.Manu_fa_ct_urer_❑___8.Volunteer FD or Rescue Service
DATE OF EXAM: Saturday Apr 12, 2014 8:00 a.m. 21-day Advance Registration Required
TESTSITE# I1441214 City,St Indianapolis,
*Note:Re-certification exams are for technicians whose certification is expiring. EVr Certification reserves the right to affirm to interested parties
-a maximum of two regular exams or six*recertification exams or one regular&three*re- the areas in which a technician is EVr Certified, �� 3
certification exams may be taken L)
Regular Recertification* Applicant's Signature: Pe Gk'
$50.00 $30.00 E' /
Fl E] F-1 Inspection,Maintenance&Testing Date:E
F2 ❑ ❑ F-2 Fire Apparatus Design&Performance Fees:
F3 ❑ ❑ F-3 Fire Pumps&Accessories Number of: o rJ
F4 ❑ ❑ F-4 Fire Apparatus Electrical Systems Regular exams: X$50.00=$ �
FA4❑ ❑ FA-4 Advanced Electrical Systems Re-certification exams:_X$30.00=$
to take the FA-4 you must have F4 or E2 Registration Fee:ane-time fee for
FS ❑ ❑ F-5 Aerial Fire Apparatus NEW registrants only $20.00=4_
F6 ❑ ❑ F-6 Allison Automatic Transmission Total Fees=
F7 ❑ ❑ F-7 Foam Systems Confirmation letter and a picture ID is required at exam site
F8 ❑ ❑ F-8 Hydraulic systems We will mail a confirmation letter within 2 business days of
EO E-0 Inspection,Maintenance&Testing receiving iL If you do not receive one,please call the EVr
office immediately.
EI ❑ ❑ E-1 Ambulance Design&Performance Visit us online at:www.evtLc.org
E2 ❑ ❑ E-2 Ambulance Electrical Systems
E3 ❑ ❑ E-3 Ambulance HVAC
E4 ❑ ❑ E-4 Ambulance Body&Chassis
Al ❑ ❑ A-1 ARFF Vehicle Design&Performance
A2 ❑ ❑ A-2 ARFF Chassis&Components
A3 ❑ ❑ A-3 ARFF Extinquishment Systems
LS ❑ ❑ L-1 Law Enforcement Vehicle Installation
Mi. ❑ ❑ M-1 Management Level I Supervise
M2 ❑ ❑ M-2 Management Level II Supervisor
to take the M-2 You must be certified in MI
Method of Payment:1-1 Visa 1-1 Master Card 1_I.Money Order 1-1 Check#
Credit Card#LI—I—i—I i_I_I—I—I I—I_I-1—I I—I—i_I_I Security Code I—I_I_I Expiration Date 1_I-1
(from hack of card) Month/Year
Name on credit card and billing address(if different from applicant's name and mailing address)
Sionature of credit card holder; —
Mail or fax this form and payment to:EVr Certification Commission,Inc.PO Box 894 Dundee,IL 60118
February,1.2011 Phone:847-426-4075 FAX;847-426-4076
https:Hregister.evtcc.org/page/printreg?txt socnum=7153&txt_firstname=Robert+&txt middlena... 2/20/2014
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))
EVT Testing $100.00
1 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
VOUCHER NO. WARRANT NO.
ALLOWED 20
EVT Certification Commission, Inc,
IN SUM OF $
P.O. Box 894
Dundee, IL 60118
$100.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
r
1120 I I 43-570.04 I $100.00 1 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
FEB 2 4 2014
Fire Chief
Title
Cost distribution ledger classification if t
claim paid motor vehicle highway fund