231703 04/23/14 ;�'' CITY OF CARMEL, INDIANA VENDOR: 357526
d it ONE CIVIC SQUARE HENRY SCHEIN INC CHECK AMOUNT: $ .....394.40'
,. i° CARMEL, INDIANA 46032 DEPT CH 10241 CHECK NUMBER: 231703
+�,,._- . . PALATINE IL 60055-0241 CHECK DATE: 04/23/14
��ON�
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 2464165-01 140.00 SPECIAL DEPT SUPPLIES
102 4239011 4768791-01 254.40 SPECIAL DEPT SUPPLIES
ORDER# ORDER DATE IDUE DATE
18391478 04/09/14 05/09/14
D&B#:01-243-0880
WHSE DEA# RHO]62494 Fed ID: 11-3136595
This order has been processed by our MIDWEST D.C.
5315 WEST 74TH 3TREET
INDIANAP)LIS,IN 46268
THOMAS D. S14ALL
EMS CHIEF
CARMEL FIRE DEPARTMENT
2 CIVIC SQUkRE, CARMEL IN 46032
317-571-260) HEADQUARTERS
317-571-266) FAX
rSMALL@CARMEL.IN.GOV
1 890-6868 3/PK LIFEPAK 12 PAPER EKG 24 24 10.60 254.40 1
PLEASE REFEZ TO BACK OF PAPERWORK FOR DISCLOSJRES/TE ZMS OF SALE
MERCHANDI E TOTAL 254.40
Invoice Date + 30 days 254.40
lease remi-I payments only to the following aldress:
Henry Scheii, Inc.
Dept CH 102 1
Palatine, IL 60055-0241
--
BILL TO SHIP TO INV OICEil INVOICE AMOUNT ITEM STATUS KEY REM� KEY�
B-Backordered:Item will tollow SK-School Kit
1308571 1308572 4768791-01 254 .40 D-Dkcconfinucd:Item no longer available NC-No Charge
I� _Special Schein 1'ree Goods
ORDER# ORDER DATE INVOICE DATE # OF 13OXES NI-Nlanulacturer will ship Item directly to you
11 Prescription Drug:Return Authorization Required
183 91478 04/09/14 4/09/14 1 R ReIrigerated Item:May be shipped separately
$ Special Schcin Pricing
CUSTOMERPO# PAGE# T Taxable Item
1 Temporarily unavailable:please reorder
TOM SMALL 0) 1 Item has MSDS
pointsrcreditsredeemable for certain goads or services,in accordance with discount program
uipment:
rales.Upon discount receipt by redemption of your earned points/credits,you are receiving or E�
will receive notice of the discount value.Accordingly,you should retain these records. Opened and used equipment may not be returned for credit.Before opening
?quipnienl,vie suggest that you check the shipping container and packing list to
DELIVERY TERMS: ensue;that you are getting exactly Mihai you ordered.Fginpmrnt must be returned
Unless otherwise agreed,height terms are FOB Shipper's Dock("Ex Works'outside in the,original unopc;ncd ackaging,unmarked and properly packaged.Sprical under
North Arnadcal.Title passes ai the;time the shipment is loaded of the shipper's dock. equipment is not returnable.Alrequipmenl returns are subject to a restocking lee.
Equipment is backed by the rrianufacturer's repair or replacement warrant:.Please
Continental U.S.: read and return all warranty information required immediately upon taking delivery of
All orders will be subject to a handling charge.This charge indudos freight,exceptfor your new equipment.(Dpen or defective equipment is subject to the:manufacturer's
additional carrier charges related to special delivery services and hazardous material warranty.
shipments.Special orders are subject to additionar freight chargers. Prescription Drug Returns:
Alaska Hawaii&Pacific Protectorates: Please note that.in order to comply with F,:deral and State Perligree requirements,
Standard shipping methods provide direct,reduced cost.expedited air delivery 1-1 on r✓Schein's policy on the return of Rx Drugs is as follows:
service to all accounts in Alaska and Haviaii.Customers in the Pacific Protectorates Rx Drugs which Henry Schein has purrhased from wholesalers ate.not returnable.
arc offered direct surface transport,or postal scrvices for reliable delivery. These items will be identified in your invoice with the node bVH.
No additional surcharges apply,except when special services are requested. Rx Drugs which are purchased by Henry Schein directly from the manufacturer may
Low-leve;i hazardous items(dangerous grinds in accepted quantities and Consumer be returned providing that the toflowing key elements are meL
Commodity ID 8000)are now available via LIPS 2nd-day air.
1 Only returns Blue to furor in order or delk"fily will be allowrid.
Guam Puerto Rico.ILS.Trust Territories k Virgin Islands: 2)Returns of Rx Drugs Will only be accepted if HSI is nolified within 14 calendar days
• All orders will be Subject to a handling charge.This charge includes freight through of receipt of the shipment arid valid return authorization is issued by HSI.
the United States Postal Service(USPS). 3)The Prescription Drug Marketing Act requires any customer returning Ffx Drugs
• Special deliirery oidf:rs and hazardous material shipmf:nts ran he shipped,via United to complete and return a Prescription Drug Return Authuri7ationform.Federal raw
Parcel Services(UPS)for an additional charge.No minimum order amwi
amount or eight requires that the healthcare entity returning Rx Drugs document that the product
applies.Speak to your International Representative for details. was kept under proper storage.and handling conditions'While in their possession
Outside U.S. 50 stalest: and during the return of the product.-to get a copy of the form and proper return
authorization,please contact Customer Service.
It your order is being shipped outside the U.S.050 states);please refer to the 4)In addition,Pedigree regulations require that the healthcare entity returning
International Terms&Conditions at henr,lschein.cum.Uhfess other vise agreed, Rx Drugs certifies
freight terms are FC?B Shipper's Dock("Fs Works"outside North Amedra). that the product being returned is the same exact product purehasnf from HSI.
Fitle passes at the time the shipment is loaded at the shipper's dock. 5)Hf;nry Schein will not issue credit for any returned Rx Drugs which have been
Customer is responsible for compliance with any applicable import requirements. tampered with,are out of date or where:the labeling has been alleTed in any viay.
RX PRODUCTS & CONTROLLED SUBSTANCES: CHOOSEYOUR PAYMENT METHOD
Hegulations require us to limit the sale of Bx and controller substances only to registered, 2%Cash Back or Maximum Rewards on all purchases with the Henry Schein
licensed healthcare prolessicmals.It you are a new customer or have recently moved, Credit Card.To apply now,call:1.866.398.9296 or online
please furnish us with a copy of your updated stale UEJl registration.For controlled www.henryscliein.conilereditcard Reduce the cost and administration of paying
substanccs,furnish a copy of your DEA registratiun verifying your shipping address. HenrySchein-Pay electronically ACH Debit)or set AutoPa
Please note;that all orders for controlled substances are subject to a due diligence review N y y( ) y'
pcucess.Schedule i1 controlled substances can be ordered c:fecironicaffy or by mail. Please call Customer Service for details.
For information on our Controlled Substance;Ordering System please visit For your convenience,'we provide several payment alternatives.Orders Billed to your
wv)Av.henrvschein.com/e2V.if you prefer to continue using Federal'.' 2 Forms to order account may be paid by ACH Debit,Check by Phone,of Check If you prefer,
Scheldule 11 controlled substances,please mail the form to: VOL(roily useynur Henry Schein Credit Card:American Express;Tisa,MasterCard or
Henry Schein,Inc. • Suite 300.5315 West 74th Street • Indianapolis,IN 46268 Discover Card;when placing_lour order.All sales are subject to our normal terms and
REGULATORY REQUIREMENT: conditions.All sales are.subject to credit approval.Invoices are payable within agreed
Local regulatory requirements rnav apply to use or installation of certain products. terms of sale.
Be sure to understand and comply with any such requirements prior to purchase,use, Open Accounts Receivable:
or installation of products. All unpaid accounts receivable past due are subject to a 1.50",finance charge.
To arrange for a product return,simply call Customer Service as noted below:
Henry Schein Medical 344B Program Henry Schein Medical/EMS
Customer Service: 1.600.472.4346 Barn-fvprn,ct. Customer Service: 1.877.344.3402 8:30dm-5:30prn.et. Customer Service: 1.800.845.3550 8:3Wm 5:30pm,ei.
Place an Order: 1.800.772.4346 Sam-9pm;et. Place an Order: 1.877.344.3402 9:30am-5:30pm.et. Place an Order: 1.600.845.3550 8:30am-5:30pm,et.
Fax an Order. 1.800.329.910924(lours. Fax an Order: 1.666.685.2253 24 ifoms. Fax an Order_ 1.800.533.4793 24 Hours.
Internet: www.henrVscheiii.com/meclical E-Commerce Support: 1.800.711.6032 8am-91-1,m;et. Internet: www.henryschein.com/ems
E-Mail: custsery@henryschein.com Internet: www.henryschein.comr34011 E-Mail: scoti.bruner0henryschein.com
E-Mail: customecsupport4henryschein.coin
Pk;ase see:lilt p:/,Wwvv.Hemyschein.com,US-EN,Medical(LegalTerms.ASPX for Conditions R Fxre;pfions.
ORDER{! ORDER DATE IDUE DATE
L18019195 04/03/14 05/08/141
D&B#:01-243-0880
WHSE DEA# RHO]62494 Fed ID: 11-3136595
F
-s'
Ln,
W115
rHOMAS SMAL,
317-571-260)
1 499-6529 EA G1 TRAVERSE PACK TACTICAL BLACK 5 5 28.00 140.00
PRODUCT IS 3EING SHIPPED TO YOU DIRECTLY FROM THE MAqUFACTLRER.
rHE PRICES 3TATED ABOVE MAY REFLECT A DISCOUN" OR BE SUBJECT TO A REBATE YOU
4UST FULLY D ACCURATELY REPORT THIS STATED DISCOUNPRIG , OR IF APPLICABLE,
WY NET PRI-ING, AFTER GIVING EFFECT TO ANY REBATES, TO MEEICARE, MEDICAID,
rRICARE AND ANY OTHER FEDERAL OR STATE PROGRAM UPON EQUESI By ANY SUCH FROGRAM.
IT ISYOUR ZESPONSIBILITY TO REVIEW ANY AGREEMENTS OR OTHEF DOCUMENTS APPLICABLE
TO THESE PZICES TO DETERMINE IF THEY ARE SUB ECT TO A REB TE. THE FEDERAL
SOVERNMENTI4POSES CERTAIN RESTRICTIONS ON, AND REQUIZES PUELIC REPORTING OF,
rRANSFERS 0 VALUE TO A PRACTITIONER. IF YOU ARE PARTICIPATING IN A PROMOTIONAL
ISCOUNT PR GRAM (E.G. POINTS, DISCOUNT REDEMPTIONS )R OTHER SPECIAL AWARDS) ,
ITH YOUR P RCHASES YOU MAY EARN POINTS/CREDI -S REDEEMABLE FOR CERTAIN GOODS OR
ERVICES, I ACCORDANCE WITH DISCOUNT PROGRAM RULES. UPON EISCOUNT RECEIFT BY
EDEMPTION F YOUR EARNED POINTS/CREDITS, YOU ARE RE'-EIVINC OR WILL RECE-VE
,OTICE OF T DISCOUNT VALUE. ACCORDINGLY, YO J SHOUL) RETAIN THESE RECORMS.
-------------
MERCHANDISE TOTAL 140.00
Invoice Date + 30 days 140.00
Please remi: payments only to the following address:
Henry Scheii, Inc.
Dept CH 102 1
Pala t ine, 1 60055-0241
BILL TO SHIP TO INV OICE# INVOICE AMOUNT ITEM STATUS KEY REM KEY
13
Y3-13ackordercel:Item will follow -School
1308571 1308572 2464165-01 140 .00 �)-Discontinued:Item no longer available NC-No Charge
I.--Special Schen I�rec Goods
ORDER# ORDER DATE INVOICE DATE # OF BOXES NI-Manufacturer will ship Item directly to you
11 Prescription Drug:Return Authorization Required
18019195 04/03/14 4/08/14 R RcfirBerated Item:May be shipped separately
CUSTOMER PQ# PAGE# $ Special Schein pricing
T Taxable Item
U-Temporarily unavailable:please reorder
THOMAS SMALL —1 OF 1 * -Item has MSDS
porinsicremts reoeemamelotcertaingoonsorwrvices,uraccuruaucewuuurswuetplug)cull
rules.Upon discount receipt by redemption of your earned points/credits,you are receiving or Euipment:
will receive notice of the discount value.Accordingly,you should retain these records. Opened and used equipment may not be returned for credit.Before opening
equipnient.we suggest that you check[tri;shipping container and packing list to
DELIVERY TERMS: ensure that you are getting exactly what you ordered.Fquipment must be returned
Unless otherwise agreed,height terms are FOB Shipper's Dock("Ex Woiks'outside in the original unopened pa!,•kaoing,unmarked and properly packaged.Speical order
North America).Title passes at the time the shipment is loaded at the shipper's dock. equipment is riot feturna le.Allequipment returns are.subject to a restocking fee.
Equipment is backed by the manufacturer's repair or replacement warranty.FIlease
Continental U.S.: read and return all warrant.,information required immediately upon taking delivery of
All ordors will be.subject to a handling charge.This charge includes freight,except for your near!equipment.;-pen or defective equipment is subject to the manufacturer's
additional carrier charges related to special delivery services and hazardous material warranty.
shipments.Special orders are subject to additional freight charges. Prescription Drug Returns:
_ Alaska Hawaii&Pacific Protectorates: PI<:ase note that.in order to rompfy with Federal and Slate.Pedigree ri:quirr:menis,
Standard shipping methods prwtide direct.reduced cost.expedited air delivery lienr>Schein's policy on the return of Rx Drugs,is as follows:
service to all accounts in Alaska and Hawaii.Customers in the Pacific Protectorates Hx Drugs which Henry Schein has purchased from whofesalefs are not returnable.
are offered direct surface transport,or postal services for reliable delivery. These items will be identified in your invoice with the code LVH.
No additional surcharges apply,except when special servir:es are requested. Rx Drugs which are purchased by Henry Schein directly from the manufacturer may
Lots-level hazardous items(dangerous goods in accepted quantities and Consumer be returned providing that the toflowing key elements are mel
Commodity ID 8000)are ncvw available via LIPS 2nd-day air.
1 Only returns due to error in order will be allOwr:d.
Guam Puerto Rico U.S.Trust Territories P.Virgin Islands: 2)Returns of Rx Drugs will only be accepted if HSI is notified within 14 calendar days
• All orders will be subject to a handling charge. ]his charge includes freight through of receipt of the shipment and valid return authorization is issued by HSI.
[he United States Postal Service(USPS). 3)The Prescription Druce Marketing Art requires any customer returning Rx Druos
• Spr:cial delivery orders and hazardous material shipments can be shipped via Hnited to complete and return a Prescription Dieu Return Authorization form.Federal law
Parcel Services(UPS)for an additional charge.No minimum order amount Or weight requires[hit[the heal[hi:are entity re.turnuiy Rx Drugs document[hat the product
applies Speak to your International Representative for details. was kept under proper storage.and handling conditions while in their possession
and during the return of the product. to ae[a copy of the toren and proper return
Outside LLS.(50 states): authorization,please contact Customer Service.
If your order is being Shipped outside the U.S.(50 states);please refer to the 4)In addition.Pedigree regulations require that the healthcare entity returning
International Terms&Conditions at henr;rsrhs!n.coni.Unfess otherwise agreed, Hx Drugs certifies
freight terms are FCiB Shipper's Dock(Tx Works"outside North America). that the product being returned is[he.same exact product purchased from HSI.
Title passes at the time the shipment is loaded at the shipper's dock. 5)Henry Schein will not issue credit for any returned Rx Drugs which have been
Customer is responsible for compliance with any applicable import requirements. tamperer)with,are out of date or where the labeling has been aflefed in any way.
RX PRODUCTS & CONTROLLED SUBSTANCES: CHOOSEYOUR PAYMENT METHOD
Regal glints require us to limit the sale of fix and coritro!led substances only to reglstereri, 2%Gash Back or Maximum Rewards on all purchases with trio Henry Schein
licensed healthcare professionals.It yvu are a new customer or have recently moved, Credit Card.To apply now,call:1.866.398.9296 or online
please lumish its with a copy of goof updated stale DEA registration.For controlled www.henryschein.com/creditcard Reduce the cost and administration of paying
substances,furnish a copy of your DEA registration verifying your shipping address. Henry ScheirrPay electronically(ACH Debit}or set up AutoPay.
Please note that all orders for controlled substances arc;subject to a due diligence review
process.Schedule II controlled substances can be ordered electronically or by mail. Please call Customer Service for details.
For information on our Controlled Substance Ordering System please visit For your convenience,'we provide several payment alternatives.Orders billed to your
�v�,Av.henrvschein.com/e222:if you preferfo conlinue using Federal 222 Forms to eider account may be paid by ACH Debit,Check by Phone,or Check. If you prefer,
Schedule Cl controlled substances,please mail the form to: you may useyour Henry Schein Credit Card;American Express,Visa, MasterCard or
Henry Schein,Inc. • Suite 300.5315 West 74th Street • Indianapolis,IN 46268 Disrover Card when placing your Order.All sales are subject to our normal terms and
c:ondilions.All sales are subject to credit approval.Invoices are.payable within agreed
REGULATORY REQUIREMENT: I approval.
Loral regulatory requirements nix,,apply to use or installation of certain products. terms of sale.
Be Sure to understand and comply with aro_!such requirements prior to purchase,use, Open Accounts Receivable:
or installation of products. All unpaid accounts rereivable past due are subject to a 1.,5%finance charge.
To arrange for a product return,simply call Customer Service as noted below:
Henry Schein Medical 340B Program Henry Schein Medical/EMS
Customer Service: 1.800.472.4346 Barn-9prn,of. Customer Service: 1.877.344.3402 8:3(k,m-5:30pm,el. Customer Service: 1.800.845.3550 8:3Wm 5:30pm,el.
Place an Order: 1.800.772.4346 13am-9pm,et. Place an Order: 1.877.344.3402 8:30am-5:301)m,et. Place an Order: 1.800-845.3550 8:30am-5:301)m,et.
Fax an Order. 1.800.329.9109 2.4 flours. Fax an Order. 1.886.885.2253 24 Hours. Fax an Order 1.800.533.4793 24 Hours.
Internet: www.henryschein.com/medical E-Commerce Support: 1.800.711.6032 Elam-8pni,et. Internet: www.henryschein.coni/encs
E-Mail: custservs@henryschein.com Internet: www.henrVschein.com/340B E-Mail: scott.bruner@henryschein.com
E-Mail: cnstomecsupport@hearyschein.com
Please see:hit p:/,`www.Henry schain.com,US-EN/Medical/LegalTerms.AS PX for Conditions&Fxceptions.
LP300
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))
4768791-01 $254.40
2464165-01 $140.00
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
120-
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Henry Schein
IN SUM OF $
Dept Ch 10241
Palatine, IL 60055
$394.40
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 4768791-01 102-390.11 $254.40 1 hereby certify that the attached invoice(s), or
1120 2464165-01 102-390.11 $140.00 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
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund