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Home My WebLink About244562 04/21/15 (9, CITY OF CARMEL, INDIANA VENDOR: 00350364 ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $""""716.45' CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK NUMBER: 244562 INDIANAPOLIS IN 46204 CHECK DATE:. 04/21/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4340701 32842 00-25380 716.45 PHYSICALS Public Safety Medical - INVOICE o Public Safety Medical Invoice Date: 04/02/2015 r 324 E. New York Street Invoice# 00-25380 E Suite 300 Terms: W Indianapolis, IN 46204 ,:m t. Carmel Police Department/CARMEPD ill to- " 3 Civic Square - Carmel, IN 46032 m.. Exclusively Serving Public Safety Professionals Since 1990. Date Employee Description Amount -" Balance Due 03/25!15 Gilmore Jason M. Chart Review/Com letion $89.85 $89,85 Indiana PERF Exam $201.90 $201.90 I� Drug Screen 9 +Opiates&Oxycodone $44.38 $44.38 Tonomet Glaucoma Test $39.94 $39.94 Urinalysis-Dipstick $3.33 $3.33 EKG W/Interp $22.18 $22.18 Audiometry 15.54 $15.54 PFT-Pulmonary Function Test $36.61 $36.61 Vision-Color Ishihara 28.84 $28.84 Vision-Acuity 28.84 $28.84 Vital Signs-HT WT BP P R $0.00 $0.00 Applicant Blood Panel-PERF $127.38 $127.38 Tb Skin Test $7.77 7 77 Chest X-Ra -PA/LAT(Digital) $66.56 $66.56 venipuncture 3.33 3.33 Total Charges-> $716.45 Total Payments&Balance Due-> $0.00 `$716.45' Please write invoice number on payment check. Our Federal Employer identification number is 35-2079797. We greatly appreciate the opportunity to serve you. If you have any questions regarding this invoice, please contact Debbie Pieper at 317-964-2330. City ®f�° �� INDIANA RETAIL TAX EXEMPT PAGE ,J,J�lrrCERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER FEDERAL EXCISE TAX EXEMPT 32 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 ACCOUNTS FOR CITY OF CARMEL- 1997 PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION 419M 1.5 if Public Safety Medical Services Carmel Police Department VENDOR SHIP 3 Civic Square 324 E. New YoA, Suet, Suite 300 TO Carmel, IN 46032 Indianapollo, IN 46 4 (397)579eV59 CONFIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT QUANTITY I UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION Account 43-407.01 1 Each physical f®r applicant $716.45 $716.45 Sub Total: $716.45 11 �N `"Vit' °d`�� ``�`�`lv ��,•nf'�,`. i,_.`��" Send Invoice To: Gabriel Police Department Attn: pat Young 3 Civic Square Cannel' IN 46032- PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT PROJECTACCOUNT _AMOUNT Carmel Police Dept. � PAYMENT A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. -- NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED. SHIPPING INSTRUCTIONS I HEREBY CERTIFY TI�PTTHERE IS AN UNOBLIGATED BALANCE IN THIS:APP�PROPIA ION SUFFICIENT TO PAY FOR THE ABOVE ORDER. SHIP REPAID.C.O.D.SHIPMENTS CANNOT BE ACCEPTED.PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY icy SHIPPING LABELS. ( c�gW of police •THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE (V/ AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. CLERK-TREASURER DOCUMENT CONTROL NO. 328 4 2 A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE VOUCHER NO. WARRANT NO. ALLOWED 20 IN THE SUM OF$ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or INVOICE NO. ACCT#/TITLE 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 II Signature I -- '-- - Title -T Cost distribution ledger classification if claim paid motor vehicle highway fund VOUCHER NO. WARRANT NO. ALLOWED 20 Public Safety Medical Services IN SUM OF$ 324 E. New York Street, Suite 300 Indianapolis, IN 46204 $716.45 ON ACCOUNT OF APPROPRIATION FOR Carmel Police Department PO#/Dept. INVOICE NO. ACCT#IrITLE AMOUNT Board Members 32842 00-25380 43-407.01 $716.45 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 Tuesday, April 14, 2015 Chief of Police 4Z Title Cost distribution ledger classification if claim paid motor vehicle highway fund 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)) 04/02/15 00-25380 applicant testing-Gilmore $716.45 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