240385 12/16/14 (9,
CITY OF CARMEL, INDIANA VENDOR: 368970
ONE CIVIC SQUARE NCTRC CHECK AMOUNT: S 80.00CARMEL, INDIANA 46032 7 ELMWOOD DRIVE CHECK NUMBER: 240385
NEW CITY NY 10956 CHECK DATE: 12/16/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1091 4355300 59095 80.00 ORGANIZATION & MEMBER
DEC o� 2014
MOZ 6 330
NCTRC
�l;sLev CTRS 7 Elmwood Drive
i New City,NY 10956
NCTRC ANNUAL MAINTENANCE call(845) 639-1439
fax(845) 639-1471
1981 APPLICATION email nctrc@NCTRC.org
www.NCTRC.org
Name as it appears on ID ��` (-V)LI�C� 1� i(�]A Certificaattiioon Number'
Current Full l�Sailing address 1 l� J V 1�/C�.1 at U rf lJ� A a� T
City7rt��ICnl� Stat,/Province 7 -A/l�Q0 i State/PiZi12 �„
/Postal Code �� ��r� Countru-,�A
Work Phone(include area code)<-�--��l? 7 3' �4fa Home Phone(include area code) <J �
Fax Number(include area c/odeaI < 1 -7- .5 7 r3 ' 5D54 E-mail address CWA 0 l] n)idyl e 1 i C Q!��W.-a i C.0;,1,
a encu � lel Clrld� \+ �deecea+1U1/
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Agency a .ddress Ci State ro� ce rinZi ostal Code Coun '�5 CC'✓l+p9Gt(if 1 �JFG15+ CA
Employment: From U'6 / '�o t4 To / / (�i `�f ll
1. Please check the box that best describes your employment status during the past year:
Uf-,vork full-tune in TR/RT(at least 32 hours per week).
❑I work full-time at my agency,but only part of this time is in TR/RT.
Number of hours per week in TR/RT
❑I work only part-time in TR/RT(less then 32 hours per week).
Number of hours per week in TR/RT
❑l do not work in TR/RT.
❑d am not employed.
❑Other
2. Hoag would you best classify your position in�T /RT?(Select only the primary one):
❑T'herapist ❑Supervisor l:Therapist/Supervisor []administrator ❑Other
❑Educator ❑Consultant ❑Volunteer ❑Student
Please enclose the Annual Maintenance Fee of$80.00. If you are inactive,please submit the additional
required fees.
Payment Options:NCTRC accepts Credit Cards, Checks and Money Orders in US Funds.Please fill out the
appropriate selection:
❑CREDIT CARD ❑CHECK ❑MONEY ORDER
❑Visa ❑MasterCard ❑American Express
Name as it appears on card:
Card Number:
Expiration Date:
By signing below I do hereby authorize NCTRC to charge$ to the above
Visa/MasterCard/American Express Account
AgnSignature(required): 1 �C=. i1 �1 ova
Date: / V �✓ (`�
PLEASE COMPLETE MANDATORY SECTIONS ON THE BACK OF THIS FORM 4
Retised 031.3
ELIGIBILITY QUESTIONS &DECLARA'T'ION
Mandatory Sections:Please complete all sections on this page for your application to be reviewed.
ELIGIBILITY QUESTIONS:
Please complete the following questions.A"YES"response to any of the questions posted below requires supporting documentation
relevant to your response.NCTRC must be notified immediately if your response to any of the following questions changes during the
period of your active certification.
i.Do you have a disabling condition or addiction to any substance that could impair competent and objective professional petfo
ance of therapeutic recreation services and/or jeopardize public health and safety? YES: NO:
2.At any time,have you been subject to an investigation or disciplinary action by a health care organization,professional associatiop�
governmental entity or regulatory or licensing agency or authority? YES: NO:
3.Have you ever been convicted,found or entered a plea of guilty or nolo contendere,or are you presently being investigated or charged
with any felony or misdemeanor directly relatiing to therapeutic recreation services or public health and safety? YES: NO:
Questions#2 and#3 include,but are not limited to investigations or disciplinary actions by an employer,state or federal licensing
agency,and/or any crimes involving violence,rape,assault,sexual abuse,use or threatened use of a weapon,and/or the prohibited sale,
`distnbuedn or possession of a controlled substance.On an attached sheet of paper you must identify all investigations,allegations
charges and outcomes.Attach documentation if available.Note:if you are currently imprisoned,on probation or parole or a case is being
appealed,NCTRC will deny certification or recertification until 3 years following the exhaustion of your appeal,completion of probation
or parole,or final release from imprisonment,whichever is later.
DECLARATIONS-NCTRC PROCESSING AGREEMENT:
NCTRC agrees to process your application subject to your agreement to the following terms and conditions.
1. To be bound by and in compliance with all NCTRC Certification Standards and rules relating to eligibility,renewal and recertification,
including,but not limited to,payment of applicable fees,demonstration of educational and experiential requirements,satisfaction of-an-
nual maintenance and recertification requirements,compliance with the NCTRC Grounds for Sanctions and other standards,and com-
pliance with all NCTRC documentation and reporting requirements,as may be revised from time to time.
2. To authorize NCTRC to disclose,publish and/or release,in the sole discretion of NCTRC,any information regarding your certifica-
tion or recertification application or status and any final or pending disciplinary decisions to state licensing boards or ageneses,other
health-care organizations,professional associations,employers or the public.
3. To hold NC IRC ham-less and to waive,release and exonerate NCTRC,its officers,directors,employees,committee members,and
agents from any claims that you may have against NCTRC arising out of NCTRC's review of your application,or eligibility for certifica-
don,renewal,recertification or reinstatement,conduct of the examination,or issuance of a sanction or other decision.
4. To only provide information in your application to NCTRC that is tine and accurate to the-best of your knowledge.You agree to
revocation or other limitation of your certification,if granted,should any statement made on this application or hereafter supplied to
NCTRC is found to be false,or inaccurate or if you violate any of the standards,rules or regulations of NCTRC.
5. To abide by the following testing conditions:
A. NCTRC reserves the right to refuse admission to any NCTRC examination if you do not have the proper identification,or if
administration has begun.If you are refused admission for any of these reasons or fail to appear at the test site,you will not be enti-
tled to a refund or deferral of the application or examination fees.During the exam,the use of scratch paper,calculators,or reference
to textbooks or notes is prohibited and you are not allowed to remove any exam materials frons the administration room.
B. NCTRC's examinations are oily offered to individuals who are seeking NCTRC certification or recertification,and for no other
purpose. NCTRC's exams and individual questions are copyright.protected and highly confidential trade secrets. Any disclosure or
reconstruction of test questions and content shall be a violation of NCTRC rules and subject to damages including,but not limited
to,the cost of replacing the compromised question(s)and reconstruction of the exam,if advisable in the discretion-of NCTRC-. -
C. Proctors are authorized to maintain a secure and proper test administration.You may not communicate with other examinees
during the examination.Any irregular,disruptive,inappropriate or suspected cheating behavior by you may result in your relocation
or removal from the examination site and/or a refusal to release your examination scores;in such event,your examination fees will
not be refunded or deferred.
SIGNATURE:By signing,I acknowledge and affirm that I have carefully read and understand NCTRC's standards,rules and require-
ments and.that I agree to abide by these terms and to.be bound by all of the provisions of the Declarations above.
PRINTED NAME: 1 C�'� t G(�lQnSIGNATURE:3 U / / � DATE: I
CONFIDENTIALITY RELEASE (Optional): I agree that NCTRC may release my name and any contact information on record
with NCTRC to individuals and/or organizations for educational and/or research purposes.By signing this section,I understand that my
name and address will be released on mailing labels requested by organizations sponsoring educational programs,conferences,and
special research stu 'es
Applicant Signature Date
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
NCTR Terms
7 Elmwood Drive
New City, NY 10956
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
11/20/14 59095.. Certified Therapeutic Rec Specialist renewal XX1464 $ 80.00
Total $ 80.00
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
Voucher No. Warrant No.
NCTR Allowed 20
7 Elmwood Drive
New City, NY 10956
In Sum of$
$ 80.00
ON ACCOUNT OF APPROPRIATION FOR I
ti
109 -Monon Center
PO#or INVOICE NO. ACCT#/TITL AMOUNT Board Members
Dept##
1091 59095 4355300 $ 80.00 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
i
I
' I
11-Dec 2014
Signature
$ 80.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
I