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HomeMy WebLinkAbout240450 12/16/2014 9�,q,�f CITY OF CARMEL, INDIANA VENDOR: 368969 ONE CIVIC SQUARE T R B `'/ \s CHECK AMOUNT: $*******557.00* )• s �_� CARMEL, INDIANA 46032 REGISTRATION 11208 WAPLES MILL ROAD CHECK NUMBER: 240450 v �.aN FAIRFAX VA 22030 CHECK DATE: 12/16/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4357004 557.00 EXTERNAL INSTRUCT FEE City of Carmel Engineering Department One Civic Square Carmel, IN 46032 Remit to: TRB Registration 11208 Waples Mill Rd. Fairfax VA 22030 Invoice Date Invoice# Project Name Amount Paid 12/12/2014 0 Membership and Registration for Jeremy $ 557.00. Check Total $557.00 Prepared by City of Carmel 12/12/2014 MXUB 94th Annual Meeting Online www.TRB.org/AnnualMeeting (STRONGLY RECOMMENDED, CREAT CARD MY) Fax 703-631-1167 January 11-15, 2015• Washington, D.C. Mail TRB Registration & Housing; 112M Waples Mill Rd., Suite 112; Fairfax, VA 22030 Attendee Registration and Hotel Reservation Form Questions? TRBgspargo.com; 877-5B5-6006, 703-449-6418 (M-F) 8:30 am. - 5:00 p.m., EST ❑Check if this is an address change. Please print and complete all required(*)information. .<T.e-, r. e-, V. .V, OL,s"K.Ka.w . First Name* Last/Family Name* C. i .+y. .�.v�. g.i . h. e_e-, T. Nickname for Badge Title lc.1114-rv . . o.F. ,CrOl.�r�IPirl1 I r 1 1 r 1 1 r I r 1 1 1 r r 1 �. 1 . �'t. �t, I. Organizatio • Telephone* o,n.e. Address` ICIAr 1�'Lr 7•..I, I I r . 1 1 1 1 1 1 1 1 1 , ,`.l. City* State/Province* Zip/Postal Code* .U.S. ,1L, a, s.�n,wt �,v► , 4 c,0.,�,yK, �,1 ;,y<, . , g,o.J. Country* Email* (FOR CONFIRMATION I. Registration Fees` MUST SELECT ONE —_-- yyp X011 30 after Nov 30 ensite IV. Organization Type* SELECT ONE) — — ❑ General Registration _ $670 —$945 ❑U.S.DOT ❑Transit Agency One Day Registration (SELECT ONLY ONE) $385 $505 El Other U.S.Federal Government Ll University/University-Based Research ❑SUN LIMON ❑TUE ❑WED ❑Non-U.S.Government ❑Consultant/Contractor tN Young Professional(AGE 35 OR YOUNGER) ❑State Transportation Department ❑Industry/Commercial Date of Birth* PkI /b_/ VO (REQUIRED) $300 $3 ❑Other State Government ❑Association/Nonprofit ❑ Non-Member Full-Time Student ,Local or Regional Government ❑Other (SPECIFY ONLY IF YOUR Date of Birth 11A4 / DD / YY (MUST SUBMITSTUDENT ID) $160 $185 Agency (city,county,or MPO) ORGANIZATIONAL TYPE IS NOT LISTED HERE) ❑ TRB Individual Affiliate Member(CURRENT AFrER 1/1/14) $540 $790 ❑Airport ❑ TRB Student Affiliate Member(CURRENT AFTER 1/1/14) $90 $105 El Port Authority Date of Birth* LAM / DD / YY (MUST SUBMIT STUDENT ID) ❑ TRB Executive Committee;Chair of TRB Technical Activities V. Subject Areas Of Interest* Division,Group,Section,Committee(NOTSUBCOMMITTEES),Task No Fee --- -- — -- ---- Force;TRB Sustaining or Organizational Affiliate Employee; gl.Administration 8 Management ❑ Freight Transportation ❑ Pipelines Media ❑ Aviation ❑ Geotechnology XPlanning & Forecasting ❑ Member of TRB Technical Activities Division,Group,Section. ❑ Bridges & Other Structures ❑ History IjiL Policy Committee NOT SUBCOMMITTEES),Or Task Force $410 $605 P,Construction ❑ Hydraulics & Hydrology ;.Public Transportation ❑ Emeritus Member $160 $185 ❑ Data & Information Technology ❑ Law ❑ Railroads ❑ Program Presenter(MUST APPEAR IN INTERACTIVE PROGRAM) $615 $615 Design ❑ Maintenance & Preservation ❑ Research (about research) ❑ TRB Sponsor Employee �Economics ❑ Marine Transportation ❑ Safety & Human Factors ❑ I affirm that I am an employee of a TRB Sponsor.(REQUIRED) MUST BE AN EMPLOYEE OF A TAB SPONSOR DURING THE ANNUAL No Fee ❑ Education & Training ❑ Materials ❑ Security & Emergencies MEETING.IT IS ILLEGAL FOR PRIVATE CONTRACTORS,RETIRED EMPLOYEES, ❑ Energy ❑ Operations & Traffic Management ❑ Society OR OTHERS TO REGISTER AS AN EMPLOYEE OF A GOVERNMENT AGENCY. ❑ Environment ❑ Pavements ❑ Terminals & Facilities ❑ Human Factors Workshop Only ❑ Finance QS Pedestrians & Bicyclists JW Transportation, General ❑ 1 acknowledge that Human Factors Workshop Only ❑ Vehicles & Equipment registration does not include TRB housing,Annual Meeting sessions, See Below exhibit hall,Annual Meeting Online,a Final Program,or the Mobile App.I will only attend Human Factors on Sunday.(REQUIRED). VI. Payment (REQUIRED TO PROCESS FORM IF BALANCE DUE. NO WIRE TRANSFERS. Registration Fee $ Optional Fees Total $ TRB reserves the right to charge the total II. Optional Fees Advwco onsite due based on the attendee's registration INv after Nov 30 Total Payment $ category eligibility and total purchases. Human Factors Workshops (SELECT ONLY ONE) ❑ Credit card (RECOMMENDED) ❑HFA ❑HFD ❑HFG ❑ American Express ❑MasterCard ❑VISA r Expiration Dete , ❑HFB ❑HFE ❑HFH $200 $275 $ ❑HFC ❑HFF ❑HFI CARD # 1 , , , Circle your Lunch Selection:Chicken or Vegetarian ohm...1111 h... u 1...v g-dr 1...1.c.i C3 Check(Payable to TRB; U.S.funds drawn onU.S.bank; ❑Chairman's Luncheon Quantity x $70 $85 $ ���fff, check payments require additional processing time.) Circle your Entree Selection: Fish or Vegetarian Fi.h 1111 b...rv.e u.1.....11.lA,1..11•.iK..e. Lgt Purchase Order #. , New Attendees Welcome Session No Fee I-(Accepted from domestic government agencies and universities only.) .2 Individual Affiliate Membership $182 $ VII. Hotel Reservation (REGISTRATION & ALL FIELDS REQUIRED TO PROCESS. ❑ Student Affiliate Membership $118 $ - "— --` --`-—" — ---- — - -- --- - - --— Arrive: Day/Date January , 2015 ❑ TRB Minority Student Fellows Program Contribution $ Depart: Day/Date January , 2015 Total $ Choice 1 Choice 2 ❑Requests (bed size, ADA, etc.): (confirm at check-in) III. Demographics ❑Single (1 person) ❑Double (2 persons) 1.Male ❑2.Female ❑3.New Attendee ❑4.Minority Frequent Stay# (confirm at check-in) ❑Check 9 you do not want to receive the TRB E-Newsletter. Hotel rooms are limited.If your choices are not available: ❑Check if you do not want to receive exhibitor or patron mailings. ❑Do not assign a room or ❑Assign a room at any hotel If you have a disability that requires ADA accommodation, specify required aids/services by Credit Card November 30: (REQUIRED FOR ARRIVAL GUARANTEE AND CHARGED MY PER CANCELLATION&NO-SHOW POLICY) ❑Use card in Section VI or ❑Use new card ❑ American Express ❑MasterCard 13VISA r � .fir r p Expiration Date ❑Check if you will NOT pick up a printed copy of the Final Program onsite. CARD #I 1 1 r 1 1 1 r 1 1 I 1 1 1 1 1 1 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 TRB Purchase Order No. Registration 11208 Waples Mill Rd. Terms Fairfax, VA 22030 Date Due Invoice Invoice Description Date Number (or note attached invoice(s)or bill(s) Amount 12/12/2014 0 Membership and Registration for Jeremy $ _ _557.00 Total $ 557.00 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. i I TRB ALLOWED 20 Registration 11208 Waples Mill Rd. IN SUM OF$ Fairfax, VA 22030 1 i $ 557.00 ON ACCOUNT OF APPROPRIATION FOR i Board Members PO#or DEPT# INVOICE NO. ACCT#rFlTLE AMOUNT DEPT# I hereby certify that the attached invoice(s), or 0 0 2200-4357004 $ 557.00 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 G I � fI I' y �i 11 12/15/2014 ignature City Engineer Cost Distribution ledger classification if Title claim paid motor vehicle highway fund