HomeMy WebLinkAbout260288 06/28/16 (9,
CITY OF CARMEL, INDIANA VENDOR: 00350364
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: S**`****800.66*
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK NUMBER: 260288
INDIANAPOLIS IN 46204 CHECK DATE: 06/28/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 33976 00-28390 800.66 APPLICANT PHYSICALS
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
PUBLIC SAFETY MEDICAL SERVICES ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
324 E NEW YORK ST SUITE 300 IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
INDIANAPOLIS, IN 46204 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$800.66 Payee
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
Carmel Police Terms
Date Due
PQ# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
33976, 00-28390 43-407.01 $800.66 1 hereby certify that the attached invoice(s),or 5/25/16 00-28390 applicant testing-Kinghom $800.66
1110 101 1110 101
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
Tuesday,June 14,2016
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
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
Public Safety Medical - INVOICE
0 Public Safety Medical Invoice Date: 05/25/2016 ;
324 E. New York Street Invoice# 00-28390
m Suite 300 Terms: '
lz Indianapolis, IN 46204
04
C Carmel Police Department/CARMEPD
H Attn: Pat Young
m 3 Civic Square
Carmel, IN 46032
Exclusively Serving Public Safety Professionals Since 1990.
Date Employee Description Amount Balance Due
05/20/16 Kin horn Kevin M. Res irator Clearance-SS $25.00 $25.00
Drug Screen 9 +Opiates&Oxycodone $45.05 $45.05
Tonometry Glaucoma Test $40.54 $40.54
Urinalysis-Dipstick $3.39 $3.39
EKG W/Interp $22.52 $22.52
Audiometry $15.77 $15.77
PFT-Pulmonary Function Test $37.16 $37.16
Vision-Color Ishihara 29.28 $29.28
Vision-Acuity 29.28 $29.28
Vital Signs-HT WT BP P R0.00 0.00
Veni uncture $3.39 $3.39
Applicant Blood Panel-PERF 129.29 $129.29
uantiferon-Tb Blood 56.30 $56.30
Chart Review/Completion $91.20 $91.20
Chest X- ay-PA/LAT(Digital) $67.56 1 $67.56
Indiana PERF Exam $204.93 $204.93
Total Charges->1 $800.66
Total Payments&.Balance Due-> $0.00 $800.66
Please write invoice number on payment check. Our Federal Employer identification number is 35-2079797.
We greatly appreciate the opportunity to serve you. If you have any questions regarding this invoice, please contact
Debbie Pieper at 317-964-2330.
INDIANA RETAIL TAX EXEMPT Page 1 of 1
City ®f Carmel CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 33976
ONE CIVIC SQUARE 35-6000972 THIS NUMBER MUST APPEAR ON INVOICES,AIP
CARMEL, INDIANA 46032-2584 VOUCHER,DELIVERY MEMO,PACKING SLIPS,
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL-1997 SHIPPING LABELS AND ANY CORRESPONDENCE
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
6/8/2016 00350364
PUBLIC SAFETY MEDICAL SERVICES Police Department
VENDOR 324 E NEW YORK ST SUITE 300 SHIP 3 Civic Square
TO Carmel, IN 46032-
INDIANAPOLIS, IN 46204-
PURCHASE ID BLANKET CONTRACT PAYMENT TERMS FREIGHT
5547
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Department: 1110 Account: 43-407.01 Fund: 101 General Fund
1 Each applicant physicals $800.66 $800.66
Sub Total $800.66
e
Send Invoice To:
Police Department _ KevinKmghorn
3 Civic Square ''� 4
Carmel, IN 46032
C, _ �\� PLEASE INVOICE IN DUPLICATE
DEPARTMENT AccOUNT PROJECT PROJECT ACCOUNT AMOUNT
PAYMENT $800.66
SHIPPING INSTRUCTIONS 'AIP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A
PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN
'SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLI GATED BALANCE IN
'C.O.D.SHIPMENT CANNOT BE ACCEPTED. THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
'PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABE
'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 194
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDER�BY
TITL
CONTROL NO. 33976 CLERK-TREASURER