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Home My WebLink About248331 08/1 2/1 5 CITY OF CARMEL, INDIANA VENDOR: 369732 ® 4�) ONE CIVIC SQUARE G C S A A CHECK AMOUNT: $*******375.00* CARMEL, INDIANA 46032 1421 RESEARCH PARK DRIVE CHECK NUMBER: 248331 MF>uN LAWRENCE KS 66049-3859 CHECK DATE: 08/12/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 164825 375.00 ORGANIZATION & MEMBER GCSAAp1 MEMBERSHIP RENEWAL 164825 1421 Research Park Drive Lawrence,KS 66049.3859 • 785-841-2240 • 800-472-7878 • Fax 785-8323643 ------------------------------------------PAST DUE----------------------------------------- Dues Invoice: 510028 PLEASE SIGN RENEWAL AND RETURN FORM TO GCSAA W/PAYMENT Membership Cycle: 7/1/2015-6/30/2016 OR RENEW @ WWW.GCSAA.ORG Membership Class:A Class A Renewal Cycle is: 04/06/2011-04/05/2016 Your preferred mailing address: Robert D.Higgins PO BOX 960 Westfield,IN 46074-0960 UNITED STATES NEW Golf Course Information:(Provide ONLY if you have changed courses.) NEW Home Mailing Address:(Provide ONLY if you have moved.) Golf Course Name Street Street Address Address City,State,Zip City,State,Zip Country Country Phone Phone Current E-mail Information Publish E-mail address? ❑YES❑NO bhiggins@carmel.in.gov Preferred E-mail address(to be used for all GCSAA correspondence and in the Would you like to continue to receive lri YES o NO GCSAA Membership Directory). Goff Course Managementmagazine? If your position/responsibilities have changed and you have not Your current job title or position is: contacted us,please visit www.gcsaa.org/membership and complete Golf Course Superintendent a reclassification form. Titre I he certify that y information is correct. Brookshire Golf Course Facility/Company/University X Semi-private 18 Member's Signature Facility Type #Holes Renewal form will be returned to member if not signed. Please Make A Copy For Tax Purposes:f GCSAA dues are not deductible as a charitable contribution for federal income tax purposes,but may be deductible as an ordinary and necessary business expense-GCSAA estimates that 60/6 of your membership dues are not deductible as this portion will be used for advocating positions on government issues,as well as for the payment of dues tenn"life insurance for all membe s excluding students, affiliate companies,technical assistance network and non-U.S.citizens. The Environmental Institute for Golf is exempt from taxation under Code Section 501(c)(3)of the Internal Revenue Service.Your voluntary gift is deductible as a charitable contribution for federal tax purposes to the extent provided by law. ° Make checks payable to:GMM V.S.Fxe,0./y(US.da%b Craws m U.S.by k) 77 z ❑Check❑Credit Card n c „ " y Membership Duesx $375.00 Card Holder Name(please print) Pald Amount? $0.00 ___---__— ____-____ .P/20__ y TOTALDUESOWEW $375.00 w Card Number Expiration Date Voluntary,C0nm-butt6n46,m En¢lrotlmenlalInsatuteForGolf $50.00 Card Holders Signature r TOTAL DUES and CONTRIBUTION: $425.00 '7. Jom or renew tha Golden Tee Club by coutn'buung an addtttoaal' Ma h Questions? Online:www.gcsaa.org 1421 Research Park or Contact member solutions at x - �- Lawrence,KS 66049-3859 800.472-7878 Fax:785-832-3643 TOTAL AMOUNT;ENELOSED COMPLETED FORM MUST BE RETURNED WITH PA REN 164825 A Robert b.Higgins. 510028 7/1/2015-6/30/2016 $375.00 GCSAAf;11 Term Life Insurance Beneficiary Form coli[OUTS SUItiINiW MTfAS MTM CI MMCA 1421 Research Park Drive- Lawrence,KS 66049-3859 • 785-841-2240 - 800-472-7878 • Fax:78S-832-3643 If you qualify in terms of eligibility,you are automatically enrolled into the dues term life insurance group policy. This benefit is at no additional cost to you. Eligibility >- All U.S.Citizens(regardless of residence) >- Non—U.S.Citizens who are Lawful Permanent Residents(LPR) of the United States as defined by the rules of the U.S.Department of State at the time of membership. >- All membership classifications excluding:Student,Affiliate Company and Technical Assistance Network Benefits Age Life Insurance Benefit AD&D Benefit >- Underage 65 $10,000 $10,000 >- 66—69 $5,000 $5,000 >- 70 and above $1,000 $1,000 updateWe strongly encourage our:m. embers to - annual basis to ensuretheir information is current. If a beneficiary is not named,state law will govern the distribution of funds.Please take a moment and update your beneficiary information in the box below.Updates to beneficiary information will automatically replace any prior beneficiary designation(s). Surviving beneficiaries will be paid equally unless otherwise indicated. Member Informatio Member Name(Printed) O��I `i VX/ First Middle Last/Surn Member Number �� y�J Date of Birth MM/DDNYYY U.S.Citizen Yel, No❑ Lawful Permanent Resident❑ Annual Beneficiary Update PCi ary Date o Birth&Relationship to Me ber ,fie 1� l p a5�f First Middle L t/s me M DD/YYYY First Middle Last/Surname MM/DDNM Contingent Date of Bi &Relationship to Member First Middle Lasr/Su a MMIDDIYYYY First Middle LastlSurname MM/DD/YYYY You must sl n and date below in order to make your designation(s) official. Signature of Member Date �� Do VOUCHER NO. WARRANT NO. ALLOWED 20 GCSAA IN SUM OF $ 1421 Research Park Drive Lawrence, KS 66049-3859 $375.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1207 I 164825 I 43-553.00 I $375.00 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 Friday, July 31, 2015 Director, Brookshire Wclub 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)) 07/20/15 164825 Dues $375.00 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