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Home My WebLink About229453 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 printreg Page 1 of 1 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