251203 11/04/15 CITY OF CARMEL, INDIANA VENDOR: T362164
ONE CIVIC SQUARE OFFICE OF INDIANA STATE CHEMIST CHECK AMOUNT: $********45.00*
�: =a CARMEL, INDIANA 46032 PURDUE UNIVERSITY CHECK NUMBER: 251203
175 S UNIVERSITY STREET CHECK DATE: 11/04/15
WEST LAFAYETTE IN 46907-2063
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 N35567 45.00 ORGANIZATION & MEMBER
Page 1
2016 INDIANA PESTICIDE COMMERCIAL APPLICATOR RENEWAL APPLICATION
BROOKSHIRE GOLF CLUB
12120 BROOKSHIRE PARKWAY
CARMEL IN 46033-1212 Current Phone: (317)846-7431 Ext.
Current Fax:
Business a-mail: bhiggins@carmel.in.gov
Submit the Renewal Application in the enclosed envelope before December 31,2015.Those
-- applications postmarked after December 31;by law,,requird n additional 100%late fee penalty:._
NOTE:
Certification in each category is valid for a five(5)year period.
A license and technician registration is renewed each year prior to DecqE:N
3,
License Number= N35567 FEE=$45.00 wDO NOT RENEW
ROBERT DAVID HIGGINS Personal e-mail:bhiggins@carmel.in.gov
Category 3B 31 CCHs earned out of 20 required Category Expires 12/3112017
[Total Fee Due: $45.00
Submit the Renewal Application in the enclosed envelope before December 31,2015.Those
applications postmarked after December 31,by law,require an additional 100%late fee penalty.
Send to: Office of Indiana State Chemist,Purdue University,175 S.University St.,West Lafayette,IN 47907-2063
Make check payable: Indiana State Chemist
I hereby swear and affirm that the list being submitted is a true and accurate record of the current certified employees working
at this business location.I also acknowledge that failure to provide accurate information on this application
form constitutes a violation of the Indiana Pesticide Use and Application Law(IC 15.3-3.6 Section 65(11)).
�i -6YJu^f 'L-� I�L) c'
Printed Names Job title of person signing
Signature Date
FOR STATE CHEMIST OFFICE USE ONLY****
APPROVED DATE
Check No Amount Entered Under
License# GN30022 Posted Account#
RT PAL
FAL Amount
Total Fee Due: $45.00
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))
10/30/15 I N35567 I Dues I $45.00
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
Office of Indiana State Chemist
Purdue University IN SUM OF $
175 S University Street
West Lafayette, IN 47907-2063
$45.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. I ACCT#/TITLE AMOUNT Board Members
1207 I N35567 I 43-553.00 I $45.00 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, October 30, 2015
Director, Brooks e Golf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund