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Home My WebLink About240385 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/ - - l/ 1 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