251904 12/02/15 "\� CITY OF CARMEL, INDIANA VENDOR: 00353332
�' _��
ONE CIVIC SQUARE MICAH BECK CHECK AMOUNT: $********75.00*
i9 CARMEL, INDIANA 46032 C/O CARMEL UTILITIES CHECK NUMBER: 251904
+,,i*oN_�. C/O CARMEL UTILITIES CHECK DATE: 12/02/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 BECK,M 75.00 OTHER EXPENSES
APPLICATION FOR VOLUNTARY
COLLECTION SYSTEM OPERATION CERTIFICATION
Administered by the Indiana Water Environment Association's Collection System Committee
EXAM DATES: April 28 and October 27 at Clay Township/April 30 and October 29 at Fort Wayne
NOTE:A complete application form is required,including a$65.00(non-refundable)application fee for class I&II examIsignature
$75.00(non
refundable)application fee for class III&IV examinations;detailed employment information;supervisor's and applicant' ton of
your post high school educational qualifications attached. The application is to be typed,or neatly printed. Checks shall 'IWEA. Failure to
return a completed applicationform by thefinal filing date will result in your ineligibilityfor that examination and forfeitupplicationfee. ALL
EDUCATIONAND EXPERIENCE REQUIREMENTSMUSTBE METAND CLEARLYSTATED. FAILURETOMRIFYEITHEROF
THESE WILL RESULT IN INELIGIBILTY FOR THE EXAMINATION.
All applications must be receivedprior to the 2nd Thursday in March for the April Examination and the 2ndThursday ifor the October
Examination.
CERTIFICATION EXAMINATION APPLICATION,CLASS: CS-I CS-II S-III CS-IV (CIRCLE ONE)
DATE:Glx' I V
I. APPLICANT INFORMATION l
A. NAME. - 4C/ J
LastFirst Middle
B. MAILING ADDRESS I �� �� l r e p�
Le, if-� 0 �� 71007 ,ch VS7r
City ? State Zip Code County
C. WORK PHONE NUMBER:( -71 S K-S6L)l HOME PHONE NUMBER:(3 C? ) C D 49 C Z
J Area/C,ode&Number y�"" / Area Code&Number
D. E-mail Address: /�h �G l� (,d ��M� r - L dV ., 67 c
E. What is.the preferred way of contacting you?(Certifications will still be sent to mailing address. All other correspondence will occur by
your preference) CIRCLE ONE
Mailing Address E-mail Address
F. Have you previously applied for a Collection System Certificate? YES NO (CIRCLE ONE)
G. What certifications do you presently hold? List all that apply:
Certification Number State Grade Class
Water Treatment
Water Distribution J
Municipal Wastewater Treatment I- o
Industrial Wastewater Treatment 1
Wastewater Collection System ` ^ 0(0—
Other —Other
II. EDUCATION AND TRAINING
A. High School: Name of School: /�1 �J Locati n: r�'�� �� uv� I (�
Years Attended: 12 Date of Graduation: 06101
B. College: Name of School: Location:
Years Attended: Date of Graduation:
C. NOTE: Attach verification of your post-high school educational qualifications. Copies of college transcripts or certificates of
completion for courses related to wastewater treatment/collection provide acceptable proof of educational qualifications. You may
list training courses,short courses,or other courses in the wastewater field that you have attended on Page 4. Include only post high
school information
III. WORK EXPERIENCE HISTORY
List your present employment first then any additional employment. Give a detailed description of your collection system work
experience as designated below. If you are not a full-time Collection Systems Operator, sped the average number of hours per
week that are spent in the actual operation and maintenance of the collection system. NOTE. If you are applying for a Class
III or IV examination, clearly define AND document your "in-charge"experience and qualifications (supervision does not
necessarily dictate "in-charge"experience).
CURRENT EMPLOYMENT:
Current Employer: t)'� C Dates—From d / Ov to Present
Job Title: 1 Q}pr�)_�Of- Number of Persons Supervised:
Job Description:
Collection System Duties: t'
Classification of Wastewater Treatment Plant: Municipal- I II III V (Circle One)
� Industrial- I-SP A-SO A B C D
Wastewater Treatment Plant Capacity: t`, !�'1 Jam, Gallons Per Day(gpd)
Supervisor's Name:
Address: 7C Cl�l ��'?a� (f' �fI f rk L Y
Phone No.: ( )
PRIOR EMPLOYMENT:
Past Employer: Dates—From / to
Job Title: Number of Persons Supervised:
Job Description:
Collection System Duties:
Classification of Wastewater Treatment Plant: Municipal- I II III IV (Circle One)
Industrial- I-SP A-SO A B C D
Wastewater Treatment Plant Capacity: Gallons Per Day(gpd)
Supervisor's Name:
Address:
Phone No.: ( )
IV. ADDITIONAL EDUCATION(Attach Copy of Completion Verification and/or Transcripts)
1. NAME/DESCRIPTION OF COURSE: killirv-0-1
o v, 2 Z I
(Location) (Dates) (College Units or Class Hours)
2. NAME/DESCRIPTION OF COURSE:
(Location) (Dates) (College Units or Class Hours)
3. NAME/DESCRIPTION OF COURSE:
(Location) (Dates) (College Units or Class Hours)
4. NAME/DESCRIPTION OF COURSE:
(Location) (Dates) (College Units or Class Hours)
V. SUPERVISOR'S VERIFICATION OF CURRENT EMPLOYMENT(to be completed by pre7W7��/-
to
I hereby verify that the information contained in the current em to ent section of thea lication made b P Ym pP Y be true and correct to the best of my knowledge and belief.
Date
Supervisor's Signature
Title
Printed
VI. SIGNATURE OF APPLICANT
I,the undersigned,certify that I am the above applicant;that all statements made and information contained in this application
are true tothe best of my knowledge and belief;that I understand that any omissions or misrepresentations may result in
ineligibility for the examination applied for. I also consent to a thorough investigation of my employment record and other
qualificatio s," relate _acts s for the purpose of verification of my qualifications for the certificate for which I have applied.
(Signature of Applicant) (Date)
Completed application form with check/money order for proper amount,and payable to IWEA,should be returned to:
IWEA
200 South Meridian Street
Suite 410
Indianapolis,IN 46225
NOTE:DUE DATE FOR APPLICATIONS,MARCH 12,2015.FOR SPRING EXAM/SEPTEMBER 10,2015 FOR FALL EXAM
LATE APPLICATIONS WILL NOT BE REVIEWED.
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VOUCHER # 156747 WARRANT # ALLOWED
T9966
IN SUM OF $
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BECK MICAH
WASTEWATER PLANT
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Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
I
PO# INV# ACCT# AMOUNT Audit Trail Code
4 i
BECK,M 01-7040-01 $75.00
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Voucher Total $75.00
Cost distribution ledger classification if
claim paid under 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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T9966
BECK, MICAH Purchase Order No.
WASTEWATER PLANT Terms
Due Date 11/24/2015
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
I
11/24/201: BECK, M $75.00
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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
Date Officer