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CITY OF CARMEL, INDIANA VENDOR: 355031
ONE CIVIC SQUARE COMMUNITY.OCCUPATIONAL HEALTH%180OK AMOUNT: $*******188.00*
CARMEL, INDIANA 46032 7169 SOLUTION CENTER CHECK NUMBER: 250624
CHICAGO IL 60677-7001 CHECK DATE: 10/21/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 430671 94.00 MEDICAL FEES
1091 4340700 430671 47.00 MEDICAL FEES
1125 4340700 430671 47.00 MEDICAL FEES
1
Community Occupational Health Svs
7169 Solution Center
Chicago, IL 60677-7001
Phone: 317-621-0341
FEIN: 35-1955223 OCT U 2015
]B'Y
Invoice
September 15, 2015
Bill to: Lynn Russell For: Cannel Clay Parks & Recreation
Cannel Clay Parks & Recreation 09/15
1411 E. 116th St.
Carmel, IN 46032-
_.___-- - .. .._�.__.___.. . __...._-...__.._.... . ., ..._.-_-_,__..._.._....._ w-_.__.__._
Invoice# 430671
Proc Code ICD9 Date Description QtV Change Recei t Ad'ust Balance
746404 09/01/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Labria T Bebley Balance Due: 47.00
746404 1)847.1 09/10/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
2)E927.0
Andrew W Burnett Balance Due: 47.00
746404 09/05/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Preston M Stacy Balance Due: 47.00
746404 09/03/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Jeremiah A Ward Balance Due: 47.00
Invoice# 430671 Balance Due: 188.00
PLEASE REMIT PAYMENT PROMPTLY
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Cut and return with payment
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ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
355031 Community Occupational Health Services Terms
7169 Solution Center
Chicago, IL 60677-7001
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
9/15/15 430671 Pre-employment drug testing $ 47.00
9/15/15 430671... Pre-employment drug testing $ 47.00
9/15/15 430671 Pre-employment drug testing $ 94.00
Total $ -
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
Voucher No. Warrant No.
355031 Community Occupational Health Services Allowed 20
7169 Solution Center
Chicago, IL 60677-7001
In Sum of$
$ 188.00
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO#or INVOICE NO. ACCT#/TiTLE AMOUNT Board Members
Dept#
1125 430671 4340700 $ 47.00 1 hereby certify that the attached invoice(s), or
1091 430671 4340700 $ 47.00 bill(s) is (are)true and correct and that the
1081-99 430671 4340700 $ 94.00 materials or services itemized thereon for
which charge is made were ordered and
received except
October 16, 2015
Signature
$ 188.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund