242749 03/03/15 Cqq
J' ''• , CITY OF CARMEL, INDIANA VENDOR: 357526
ONE CIVIC SQUARE HENRY SCHEIN INC CHECK AMOUNT: $*******301.56*
4,
a° CARMEL, INDIANA 46032 DEPTCH 10241
CHECK NUMBER: 242749
9Mc;oN ` CHECK DATE: 03/03/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 17177217 301.56 SPECIAL DEPT SUPPLIES
ORDER# bkbiiDATE-. DUE DATE
26634191 02/17/15 03/19/151
D&B#:01-243-0880
WHSE DEA# RHO 162494 Fed ID:11-3136595
mom M
IN
ENE
`., -y NOW
rhis order has been processed by our MIDWEST D.C.
5315 WEST 74TH 3TREET
INDIANAPOLIS,IN 46268
rom 02/17/1i
1 499-5085 PU EA CATHETER SUCTION 14FR 10 10 0.23 2.30 2
2 120-8808 EA COMBITUBE ROLL-UP KIT 41FR 5 5 40.96 204.80 2
3 932-7431 10/PK E-T INTRODUCER W/COUDE 1 1 47.23 47.23 2
4 110-6384 10/BX INTRODUCER PEDI COUDE/ STR TIP 1 1 47.23 47.23 2
PLEASE IZEFEZ TO BACK OF PAPERWORK FOR DISCLOSJRES/TE ZMS OF SALE
MERCHANDI E TOTAL 301.56
nvoice Date +
30 days 301.56
Please remi- payments only to the following aldress:
Henry Scheii, Inc.
Dept CH 10211
Palatine, 1. 60055-0241
.. ... ... . . . ........ . . . .... ......
BILL TO
SHIP-'TO INVOICE.. . .4. ...... I I I NVO.YC.E:A.M.0 UN.T ITEM STATUS KEY REM KEY
B-Backordered;Item will follow SK-School Kit
1308571 1817102 17177217 301.S6 D-Discontinued;Item no longer available NC-No Charge
F-Special offer IM]
DER ORDER�DATE INV DATE # OF BOXES: M-Manufacturer will ship Item directly to you
P-Prescription Drug;Return Authorization Required
26634191 02/17/1S 2/17/15 2 It Refrigerated Item;May be shipped separately
........ . .... ..- Special Schein Pricing
7 $
CUSTOMER P PAGE - T-Taxable Item
TOM 021715 1 OF 1 Item h
'I-Temporarias MSly DS unavailable;please reorder
LP300
14 1 to 4110 MUJI1111JU
piirchase(s)are subject to a bundled discount or rebate.Any such discounts must he Equipment:
calculated pursuant to the terms of the applicable purchase offer,promotion,or discount Opened and used equipment may not be returned for credit.Before opening
program.Participation in a promotional discount program is only permissible in accordance equipment,we suggest that you check the shipping container and packing list to
with discount program rules-By participation In such program,you agree that,to your ensure that you are getting exactly what you ordered.Equipment must be returned
knowledge,your practice complies with the discount program requirements. in the original unopenedpackaging,unmarked and properly packaged.Speical order
equipment is not returnable.At equipment returns are subject to a restocking fee.
DELIVERYTERIUIS: Equipment is backed by the manufacturer's repair or replacement warranty.Please
Unless otherwise agreed,freight terms are FOB Shipper's Dock('Ex Works"outside read and return all warranty information required immediately upon taking delivery of
North America).Tifle passes at the time the shipment is loaded at the shipper's dock. your new equipment.Open or defective equipment is subject to the manufacturers
Continental U.S.: warranty.
All orders will be subject to a handling charge.This charge includes freight,except for Prescription DrugRetums:
additional carrier charges related to special delivery services and hazardous material Please note that,in order to comply with Federal and State Pedigree requirements,
shipments.Special orders are subject to additional freight charges. Henry Schein's policy on the return of Rx Drugs is as follows:
Alaska.Hawaii&Pacific Protectorates: Rx Drugs wfiidi Henry Schein has purchased from wholesalers are riot returnable.
Standard shipping methods provide direct,reduced cost,expedited air delivery These items will be identified in your invoice with the rode WH.
service to all accounts in Alaska and Hawaii.Customers in the Pacific Protectorates Rx Drugs which are purchased by Henry Schein directly froin the manufacturer may
are offered direct surface trarlsport,or postal services for reliable delivery, be returned providing that the following key elements are met:
No additional surcharges apply,except when special services are requested.
Low-level hazardous items(dangerous goods in accepted quantities and Consumer 1)Only returns due to error in order or deliveiy will be allowed.
Commodity ID 8000)are now available via UPS 2nd-day air. 2)Returns of Pox Drugs will only be accepted if HSI is notified within 14 calendar days
Guam.Puerto Rico.U.S,Trust Territories&Urr in Islands: of receipt of the shipment and valid return authorization is issued by HSI.
3 3)The Prescription Drug Marketing Act requires any customer returning Rx Drur s
• All orders will be subject to a handling charge. Ihis charge includes freight through to complete and return a Prescription Drug Return Authorization form.Federa�law
the United States Postal Service(USPS). requires that the healthcare entity returning Rx Drugs document that the product
• Special delivery orders and hazardous material shipments can be shipped via United was kept under proper storage and handling conditions while in their possession
Parcel Services(UPS)for an additional charge.No minimum order amount or weight and during the return of the product.To gel a copy of the form and proper return
applies.Speak to your International Representative for details. authorization,please contact Customer SerAce.
Outside U.S.(50 states): 4)In addition,Pedigree regulations require that the healthcare entity returning
If your order is being shipped outside the U.S.(50 states),please refer to the Rx Drugs cerfifnes
International Terms&Conditions at henryschein.com.Unless otherwise agreed, that the product being returned is the same exact product purchased from HSI.
freight terms are FOB Shipper's Dock("Ex Works"outside North America) 5)Henry Schein will not issue credit for any returned Rx Drugs which have been
title passes at the time the shipment is loaded at the shipper's dock. tampered with,are out of date or where the labeling has been altered in any way.
Customer is responsible for compliance with any applicable import requirements. CHOOSE YOUR PAYMENT METHOD
—RX-PRODUCT-S-&-CONTROLLE D-SUBSTAN CES:_- 2tl/o Cash-Backor-i4laximum-Rewards-ort-all-purchaseswitlrthe-Heniy-Schcir--
Regulations require us to limit the sale of Pox and controlled substances only to registered, Credit Card.To apply now,call:1.866.398.9296 or online
licensed healthcare professionals.your
up area new customer tr have recFor coy moved, www.henrysclieiii.eciTi/creditcard Reduce the cost and administration of paying
please furnish us with a copy of your updated stale DEA registration.For controlled ry P Y 9
substances,furnish a copy of your DEA registration verifying your shipping address. Henry Schein-Pay electronically(ACH Debit)or set up AutoPay.
Please note that all orders for controlled substances are subject to a due diligence review Please call Customer Service for details.
process.Schedule II controlled substances can be ordered electronically or by mail. For your convenience,we provide several payment alternatives.Orders billed to your
For information on our Controlled Substance Ordering Systein please visit account may be paid by ACH Debit,Check by Phone,or Check.If you prefer,
mvw.tienryschein.com/e222;if you prefer to continue using Federal 222 Forms to order you may useyour Henry Schein Credit Card,American Express,Visa,MasterCard or
Schedule II controlled substances,please mail the form to: Discover Card when placing your order.All sales are subject to our normal terms and
Henry Schein,Inc.• Suite 300,5315 West 74th Street • Indianapolis,IN 46268 conditions.All sales are subject to credit approval.Invoices are payable within agreed
REGULATORY REQUIREMENT: terms of safe.
Local regulatory requirements may ap.ly to use or installation of certain products. Open Accounts Receivable:
Be sure to understand and comply w i arty such requirements prior to purchase,use, All unpaid accounts receivable past due are subject to a 1.5%finance charge.
or installation of products.
To arrange for a product return,simply call Customer Service as noted below:
Henry Schein Medical 3408 Program Henry Schein Medical/EMS
Customer Service: 1.800.472.4346 8am-9pm,et. Customer Service: 1.877.344.3402 8:3(arn.-5:30prn,el. Customer Service: 1.800.845.3550 8:3()am-5:30pm,et
Place an Order: 1.800.772.4346 8am-9pni,et. Place an Order. 1.877.344.3402 8:30am-5:30pm,et. Place an Order. 1.800.845.3550 8:30am-5:30pm,et
Fax an Order. 1.800.329.9109 24 Hours. Fax an Order 1.888.885.2253 24 Hours. Fax an Order. 1.800.533.4793 24 flours.
Internet: tvww.henryschein.com/medical E-Commerce Support: 1.800.711.6032 8am--8pin,et. Internet: www.henryschein.com/erns
E-Mail: custserv@henryschein.com Internet: =nv-henryschein.com/3408 E-Mail: scott.bruner@henryschein.com
E-Mail: customer.support@henrVschein.com
Please see:littp://wvnv.Henryschein.com/US-EN/Medical/LegalTerms.ASPX for Conditions&Exceptions.
VOUCHER NO. WARRANT NO.
ALLOWED 20
'Henry Schein
IN SUM OF$
Dept Ch 10241
Palatine, IL 60055
$301.56
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 17177217 102-390.11 $301.56 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
MAR - 2 �
Fire Chief
Title
Cost distribution ledger classification if {
claim paid motor vehicle highway fund
rescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
n invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
hom, 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))
17177217 $301.56
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