252132 12/02/15I
+uv.Cgq�f
t CITY OF CARMEL, INDIANA VENDOR: 368458
® 'a{ ONE CIVIC SQUARE HANI SOUEIDAN CHECK AMOUNT: $.."";"125.00`
,a° CARMEL, INDIANA 46032 CARMEL WASTEWAI ER CHECK NUMBER: 252132
*r�o„a� CHECK DATE: 12/02/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 125.00 OTHER EXPENSES
APPLICATION FOR VOLUNTARY
COLLECTION SYSTEM
OPERATION CERTIFICATION
Administered by the Indiana Water Environment Association's Collection System Committee
NOTE:A complete application form is required. including a$6;.nn(non-refundable)application fee for class I&H examinations and$75.00(non
refundable)application fee for class III&lV examinations:detailed emplovment information:supervisor's and applicant's signatures;and verification of
your posthigh school educational qualifications attached. The application is to be typed,or neatly printed. Checks shall be payable to IWEA. Failure to
return a completed application form by the finalfiling date trill result in your ineligibility for that examination and forfeiture of your application fee. ALL
EDUCATION AND EXPERIENCE REQUIREMENTS MUST BE MET AND CLEARLY STATED. FAILURE TO MEET OR VERIFY EITHER OF
THESE WILL RESULT IN INELIGIBILTY FOR THE ECAMIN.ATION.
All applications must be received prior to the 2nd Thursday in March for the.April Examination and the 2ndThursday in September for the October
Examination.
CERTIFICATION EXAMINATION APPLICATION,CLASS: CS-I CS-II CS-III CS-IV (CIRCLE ONE)
DATE: � /Aze/S
I. APPLICANT INFORMAZC
A. NAME J,004L kL
Last First /Middle
B. MAILING ADDRESS Z_
3G/ /tf�"i G�lc�'�� L-.
A/ Street
( L f
City State Zip Code County
C. WORK PHONE NUMBER:( ) HOME PHONE NUMBER:( yell
Area Code&Number Area Code&Number
D. E-mail Address:
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: AJ fA-
Certification/Number State Grade(Class)
Water Treatment
Water Distribution
Municipal Wastewater Treatment
Industrial Wastewater Treatment
Wastewater Collection Svstem
Other
II. EDUCATION AND TRAINING
A. High School: Name of School: , O/,!L f��/�/SC� f! Location: � i //—
Years Attended: Date of Graduation:/
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
R
7
CITY OF CARMEL Expense Report (required for all travel expenses)
NpIPNP �/ EXHIBIT A
EMPLOYEE NAME: Hani Soueidan DEPARTURE DATE: h1'6 TIME: 49"00 41 PM
DEPARTMENT: Utilities RETURN DATE: o jjS TIME: S `0 (D AM PM
REASON FOR TRAVEL: Class/Seminar DESTINATION CITY: Indianapolis
EXPENSES ARE FOR (check all that apply): TRAVEL ADVANCE TRAVEL REIMBURSEMENT TRAVEL PER DIEM
Transportation Gas/Tolls/ Meals
Date Lodging Misc. Total
Air-fare Car Rental Other Parking Breakfast Lunch Dinner Snacks Per Diem
11/18/15 $30.00 $30.00
11/19/15 $30.00 $30.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
-$0.00
$0.00
$0.00
.$0:00
$0.00
$0:00
$0.00
0.00
Total $0.00 $0.00 $0.00 $60.001 $0.00 $0.00 $0.00 $0.00 . $0.001 . $0.00 $0.00
City of Carmel Form#ER06 Revision Date 11/23/2015 Page 1
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 Svstents Operator, speck 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: A111-111K
�
Current Employer: Q� ,�/1'NC`'(, (/T/1/111K Dates—From // /,2C' to Present
Job Title: Cp�/�E?C�(L1�i .!�_�T-e'/7t141VVL hpV, Number of Persons Supervised:
Job Description:
Collection System Duties:
Classification of Wastewater Treatment Plant: Municipal- I I1 Ill IV (Circle One)
Industrial- I-SP A-SO A B C D
Wastewater Treatment Plant Capacity: Gallons Per Day(gpd)
Supervisor's Name: vt
Address: Q� ,,� Dalff
/ _ /V Z �✓
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.: ( )
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
368458
SOUEIDAN, HANI Y Purchase Order No.
SOUTH PLANT Terms
Due Date 11/25/2015
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/25/201! SOUEIDAN, $65.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and
correct and I have audited same in accordance with ICp 5-11-10-1.6
Date Officer
VOUCHER # 156750 WARRANT # ALLOWED
368458 IN SUM OF $
SOUEIDAN, HANI Y
SOUTH PLANT
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
SOUBDAN, F 01-7040-01 $65.00
HAn11T oI-104o -oi X0,00
I
p0
Voucher Total
Cost distribution ledger classification if
claim paid under vehicle highway fund