240790 01/07/15 *F . CITY OF CARMEL, INDIANA VENDOR: 00350364
s b ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: S"""'2,823.60`
r4 CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK NUMBER: 240790
*�itiN INDIANAPOLIS IN 46204 CHECK DATE: 01/07/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 R4340701 32234 00-24695 2,823.60 PHYSICAL APPLICANT
Public Safety Medical - INVOICE
F°- Public Safety Medical Invoice Date: 12/26/2014
324 E. New York Street Invoice# 00-24695
E Suite 300 Terms:
5
W Indianapolis, IN 46204
C Carmel Police Department/CARMEPD
F- 3 Civic Square
m Carmel, IN 46032
Exclusively Serving Public Safety Professionals Since 1990.
Date Employee Description Amount Balance Due
12/16/14 Babczak Brian Chart Review/Com letion $88.52 $88.52
Indiana PERF Exam $198.92 $198.92
Drug Screen 9 +Opiates&Oxycodone $43.72 $43.72
Applicant Blood Panel-PERF $125.50 $125.50
Tb Skin Test $7.65 $7.65
Chest X-Ray-PA/LAT(Digital) $65.58 $65.58
Venipuncture $3.29 $3.29
Tonometry Glaucoma Test 39.35 $39.35
Urinalysis-Di stick $3.29 $3.29
EKG W/Intero $21.86 $21.86
Audiometry 15.31 $15.31
PFT-Pulmonary Function Test $36.07 $36.07
Vision-Color Ishihara 28.42 $28.42
Vision-Acuity $28.42 $28.42
Vital Signs-HT WT BP P R $0.00 $0.00
Cra ner,William Chart Review/Completion $88.52 $88.52
Indiana PERF Exam $198.92 $198.92
Drug Screen 9 +Opiates&Oxycodone $43.72 $43.72
Tonometry Glaucoma Test 39.35 $39.351
Urinalysis-Dipstick $3.29 $3.29
i EKG W/Interp $21.86 $21.86
Audiometry $15.31 $15.31
PFT-Pulmonary Function Test $36.07 $36.07
Vision-Color Ishihara 28.42 $28.42
Vision-Acuity 28.42 28.42
Vital Signs-HT WT BP P R $0.00 $0.00
Applicant Blood Panel-PERF $125.50 $125.50
Tb Skin Test $7.65 $7.65
Chest X-Ray-PA/LAT(Digital) 65.58 $65.58
Venipuncture $3.29 $3.291
McKay.Christopher A. Chart Review/Completion $88.52 $88.52
Indiana PERF Exam $198.92 $198.92
DruQ Screen 9 +Opiates&Oxycodone $43.72 $43.72
Tonometry Glaucoma Test 39.35 $39.35
Urinalysis-Di stick $3.29 $3.29
EKG W/Intero $21.86 21.86
Audiometry 1 .31 $15.311
Public Safety Medical m INVOICE
0 Public Safety Medical Invoice Date: 12/26/2014 � E�
= 324 E. New York Street Invoice# 00-24695
E Suite 300 Terms: ,
Indianapolis, IN 462041"
o Carmel Police Department/CARMEPD
H 3 Civic Square
m Carmel, IN 46032
Exclusively Serving Public Safety Professionals Since 9990.
Date Employee Description Amount Balance Due
PFT-Pulmonary Function Test $36.07 $36.07
Vision-Color(Ishihara) $28.42 $28.42
Vision-Acuity $28.42 $28.42
Vital Signs-HT WT BP P R $0.00 $0.00
Applicant Blood Panel-PERF $125.50 $125.50
Tb Skin Test $7.65 $7.65
Venipuncture $3.29 $3.29
Chest X-Ray-PA/LAT(Digital) 65.58 $65.58
Soultz. Megan Chart Review/Completion $88.52 $88.52
Indiana PERF Exam $198.92 $198.92
Drug Screen 9 +Opiates&Oxycodone $43.72 $43.72
Tonometry Glaucoma Test 39.35 $39.35
Urinal sis-Dipstick $3.29 $3.29
EKG W/Interp $21.86 $21.86
Audiometry $15.31 $15.31
PFT-Pulmonary Function Test $36.07 $36.07
Vision-Color Ishihara 28.42 $28.42
Vision-Acuity $28.42 $28.421
Vital Si ns-HT WT BP P R $0.00 $0.00
Applicant Blood Panel-PERF $125.50 $125.50
Tb Skin Test $7.65 $7.65
Chest X-Ray-PA/LAT Di ital 65.58 $65.58
Veni uncture 3.29 $3.29
Total Charges-> $2,823.60
Total Payments&Balance Due-> $0.00 1 $2,823.60
I
INDIANA RETAIL TAX EXEMPT PAGE
City o Carmel
CERTIFICATE NO.003120155 002 0 Ja PURCHASE ORDER NUMBER
v
FEDERAL EXCISE TAX EXEMPT
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTStFOR CITY OF CARMEL 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
V11012DW4
Public BdGty NGdlcml Somicos Comel Pollco Dopa>ftntont
VENDOR SHIP 3 CIVIC squm
324 E. Now Yorh Stroot, Sulto TO Catrmol, IN 4
Indianapolis, IN 46204 (W)674
I` CONFIRMATIONBLANKET CONTRACT PAYMENTTERMS FREIGHT
I
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43 07.01
4 Each pieflical for applicant $705.90 $2,823.00
Saab Total: $2,823.50
/0
rf a
Send Invoice To: U
CzrmGI Police Depadmont
Attn: Eat Young
3 CIVIC square
Caffloi, IN PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT I PROJECT ACCOUNT AMOUNT
Carmel Police Dept. PAYMENT $2,623.00
• A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY HAT HERE IS AN UNOBLIGATED BALANCE IN
SHIP REPAID.
THIS APPROP AT FFICIENT TO PAY FOR THE ABOVE ORDER.
•
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED.
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY p
SHIPPING LABELS. ChIG?oC PollcQ
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
CLERK-TREASURER
DOCUMENT CONTROL NO. 3 2 2 311 A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE
S
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN THE SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#TFITLE AMOUNT
DEPT.# I 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— -------- ---- ---------
20
------- Signature -----------
------- - - _-... -- --
...-....-..........
.............--...-..---.....-_.. .-.-..-_....----
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
i
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))
01/02/15 00-24695 applicant testing $2,823.60
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
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$2,823.60
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Encumbered I hereby certify that the attached invoice(s), or
32234 00-24695 43-407.01 $2,823.60
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
Wednesday, D cember 31, 2014
41Z Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund