302772 09/08/16 CITY OF CARMEL, INDIANA VENDOR: 365130
J ONE CIVIC SQUARE MARK CROMLICH CHECK AMOUNT: $*******810.00*
CARMEL, INDIANA 46032 12685 LANTERN RD CHECK NUMBER: 302772
FISHERSIN 46038 CHECK DATE: 09/08/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 090616 810.00 EXTERNAL INSTRUCT FEE
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts city Form No.201(Rev.1995)
MARK CROMLICH ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
12685 LANTERN RD IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
FISHERS, IN 46038 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$810.00 Payee
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
0 43-570.04 $810.00 1 hereby certify that the attached invoice(s),or 9/1/16 0 Registration Fees-Would not bill City $810.00
1120 101 1120 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
Friday, September 02,2016
David Haboush
Fire Chief
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
120—
Cost
20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
REGISTRATION FORM 3 WAYS TO REGISTER FOR CONGRESS:
./b ONLINE: congress.nsc(preferred method)
rg FAX: (708)344-4444
National Safety Council ® MAIL: 2016 NSC Congress&Expo
CONGRESS & EXPOc/o CompuSystems
Congress:October 15-October 21 2651 Warrenville Rd.,Suite 400
Expo:October 17-19
Downers Grove, IL 60515
1. REGISTRANT INFORMATION-No one under 16 years of age is permitted to attend the 2015 NSC Congress&Expo,regardless of affiliation.
Mark Cromlich 317-409.0909
First Name last Name Phone Fax
Safey Chief
Title Cell/Mobile
Cartmel Fire Department mcmmlich@carmel.in.gov
Company Name E-mail
2 Civic Square
Address
Carmel.IN 46032 Check here if this is your first time EVER attending the NSC Congress&Expo.
city State/Province ZIP/Postal Code 0 Check here if,under ADA,you require special services in order to attend.
United States 1611 You will be contacted by NSC.
Country 0 YES NSC will behaving a Career Center at Congress.Would you be interested
O NO in making an advance appointment?
2. NSC MEMBERSHIP •• •
0 1 am a member of the National Safety 0 1 am NOT a member of the Not sure if your company is a member?
Council.My NSC Member ID#is: National Safety Council. Contact Customer Service at(800)621-7619
or customerservice@nsc.org.
DEMOGRAPHIC3. •• •
1. Job Function: 2. My Primary Expertise is: 3.Years of Experience S.Your Company's 7. Product Interest: 9.Annual Planned
(Check one) (Check one) in Field: Industry Affiliation: (Check all that apply) Purchase Amount:
O a.CEO/C00/ 0 a.Construction (Check one) (Check one) 0 a.Administrative/Risk (Check one)
PresidentlOwnerNP/Director 0 b.Educatorrrrainer 0 a.1-3 years O a.Aerospace Management/Services O�.Less than$10,000
0 b.Distributor/Sales Rep, 0 c.Engineering/Design b.4-9 years 0 b.Agriculture �b.Emergency Response g-.$10,000-$49,999
0 c.Facility Manager 0 d.Environmental Protection O c.10-19 years 0 c.Construction 0 c.Environmental Protection 0 c,$50,000-$99,999
0 d.Human Resources 0 e.Ergonomics 0 d.20 or more years Ad.Govemment/ Ad.Ergonomics 0 d.$100,000-$499,999
0 e.Industrial Hygienist Af. Fire Protection Public Administration 0 e.Facility Design, 0 e. $500,000-$1 Million
0 f.Risk Manager/ 0 g•Fleet Safety 4.Age: 0 e.Information Technology Maintenance 0 f More than$1 Million
Loss Control Manager 0 h.Hazardous Waste Materials 0 a.Under 25 0 f.Insurance and Operation
0 g.Safety Consultant/ 0 I. Home&Community Safety 0 b.25-34 0 g•Manufacturing 0 f Fall Protection
Safety Engineer 0 j. Human Resources0 It.Mining 0 g.General Safety 10. Plan to Purchase
0 h. Safety Coordinator 0 k.Industrial Hygiene 0 c.35-44 0 i.Petrochemical 0 h.Hazard Control Within the Following
�d45-54
Safety Director 0 .
I. Labor Union Representative 0 j.Professional Services 0 1.Home&Community Timeframe:
0 e.55-64
❑j. Safety VP/Administrator/ 0 m.Occupational Safety, 0 k.services(incl.health care) �•Industrial Hygiene/ (check one)
Manager/Supervisor/ Health&Environment 0 f.65+ 0 LTrades(wholesale&retail) Occupational Health 0 a.Immediately
Superintendent 0 n.Risk Management/ 0 m.Transportation 0 it.Personal Protection 0 b.1-6 months
0 k.Security Manager Loss Control/lnsurance 0 n.Utilities 0 I.Security 0 c.7-9 months
0 I.Skilled Tradesperson 0 o.Safety Management/ 0 o.Other(please specify) 0 m.Transportation 'zed.10-12 months
0 m.Union/Committee Rep. Administration
0 In. Other(please specify) 0 p.Safety Engineering
0 q.Student 6. Company Size: 8. Purchasing Role:
❑r.TraffidHighway Safety (Estimate of employees (Check one)
0 s.Other(please specify) in all locations) 0 a.Approve/Final Say
0 a.t-99 Ob.Recommend SupplierNendor
100-999 0 c.No Role
0 c.1,000-4,999
0 d.5,000+
CONGRESS4. NSC '• For details, • • (800)621-7619
FULL CONGRESS&EXPO*(Includes access to Opening Session, EXPO ONLY(Includes access to Opening Session,NSC Learning Lab Sessions and the
Keynotes,Technical Sessions,NSC Learning Lab Sessions,FREE Expo floor for three days.)
Convention Center Lunch Voucher,and the Expo floor for three days.) ONE DAY(Includes access to the Expo floor and NSC Learning Lab Sessions for one day.)
Early Rate Advance Rate Standard Rate Early Rate Advance Rate Standard Rate
(By 7115116) (By 9/9/16) _ (9110116) _- _ - _ __ - (By 7/15/16) (By 919116_)- - (9110116)
❑ NSC Member $655 $810 $900 ❑ NSC Member $150 $175 $200
❑ Non-Member $800 $975 $1100 ❑ Non-Member $175 $200 $225
Government $655 $810 5900 ❑ Distributor $150 $175 $200
❑ Student" FREE FREE FREE ❑ One Day:M❑ TO W❑ $100 $125 S15o
Check c day you plan to take ntage of the FREE Convention Center Lunch Voucher:
MONDAY TUESDAY ❑ NEITHER DAY
*Group discounts available on Full Congress&Expo pricing for companies who register 5+employees,pre-approval required.
**To qualify for student registration,you must be enrolled as a full time student in the U.S.and not currently employed as a safety professional.Student registration forms must include a copy of
valid U.S.student ID in order to be processed.Lunch is not included.Online registration is not available for Student attendees.
5. EXECUTIVE EDGE WORKSHOPS 8. NSC NATIONAL AWARD CELEBRATION
Executive Edge workshops are available to Full Congress&Expo registrants only. National Awards Celebration
For more information,please visit:congress.nsc.org. This will be held Tuesday,October 18,from 5:30 p.m.-8:00 p.m,in the Anaheim Convention Center
Code Executive Edge Workshops Rate
#of tickets x$75/ticket=$
❑ 44 Workshop A- Engaging Reliability:Culture,Communication $99 9. NSC DIVISION/SECTION
&Demographics
❑ 48 Workshop B- Resilience in Action:Executing on HRO $99 Available to NSC member companies only.Congress&Expo admission is not
&Human Performance included.All Division/Section meetings will be held at the Hilton Anaheim.For more
detailed meeting information,please visit congress.nsc.org.
TOURS6.TECHNICAL Code NSC Division/Section Meetings Cost
Technical Tours are available to Full Congress&Expo registrants only.For more 13 310 Labor Division Meeting(Union Members only) $225
information,please visit:congress.nsc.org ❑ 311 Labor Division Guest(Reception only)* $65
❑ 312 Labor Division Guest(Luncheon only)* $65
Code Technical Tours Rate Cl 313 Labor Division Guest(Reception&Luncheon)* $130
❑ 321 Construction Division Meeting&Reception $125
13TT1 Behind the Scenes:Anaheim Convention Center $40 ❑ 322 Construction Division Reception Only $60
❑TT2 Behind the Scenes:Anaheim Regional Transportation $40 ❑ 329 1 Young Professionals Division Meeting $75
Intermodal Center(ARTIC)
*Guest name
7. PROFESSIONAL DEVELOPMENTSEMINARS
1REGISTRATION
Bundle and Save!Save 10%when you register for two professional development
seminars and 20%when you register for three or more.Congress&Expo admission Registration Item Amount
is not included. -
NSC Congress&Expo(Section 4) $ 1�N\`o
Early Rate Advanced Rate Standard Rate Executive Edge Workshops(Section 5) $
(By 7/15116) (By 919116) (9110116)
Session NSC Member/ Non- NSC Member/ Non- NSC Member/ Non-
-Number Government Member Government Member Government Member _ Professional Development Seminars(Section 7) $
❑ 201 $900 $1,100 $1,000 $1,200 $1,100 $1,300 NSC National Award Celebration Section 8
❑ 202 $900 $1,100 $1,000 $1,200 $1,100 $1,300 NSC Division/Section Meetings Section 9 $
❑ 203 $300 $375 $375 $425 $400 $475 Total Registration Fees $ q
0 204 $300 $375 $375 $425 $400 $475
0 205 $300 $375 $375 $425 $400 $475
❑ 206 $300 $375 $375 $425 $400 $475 ❑ Check# (payable to National Safety Council)
Cl 207 $300 $375 $375 $425 $400 $475 >KIU.S.Government Purchase Order(must be enclosed)
❑ 208 $300 $375 $375 $425 $400 $475 ❑ AmEx ❑Discover ❑MasterCard ❑ VISA
13 209 $300 $375 $375 $425 $400 $475
❑ 210 $300 $375 $375 $425 $400 $475 Card Number Exp.Date
13 211 $300 $375 $375 $425 $400 $475
Signature
13 212 $300 $375 $375 $425 $400 $475
❑ 213 $300 $375 $375 $425 $400 $475 Print Name as it appears on card
❑ 214 $300 $375 $375 $425 $400 $475
Cancellation Policy
❑ 215 $300 $375 $375 $425 $400 $475 Cancellations received in writing on or before Friday,September 23,2016,will be refunded less
❑ 216 $300 $375 $375 $425 $400 $475 a 5100 processing fee.Cancellations received after Friday,September 23,2016,are non-refundable.
All cancellation requests should be sent to the National5afety Council,ATTN:Congress Refunds via
❑ 217 $650 $800 $800 $850 $800 $995 fax(630)285-0798 or e-mail at congressrefundswnsc.org.Substitutions/Name Changes can be
done online via the edit feature until the badge has been printed and verified.
❑ 218 $650 $800 $800 $850 $800 $995 Privacy Statement
•❑ 219 $300 $375 $375 $425 $400 $475 All contact information will be used for NSC business purposes only.We will not misuse your
information.All correspondence will be e-mailed or mailed to the address on the registration form.
❑ 220 $300 $375 $375 $425 $400 $475 The registration mailing list is made available to exhibitors only.
❑ 221 $300 $375 $375 $425 $400 $475 Program Disclaimer
NSC will make every effort to avoid changes to the program and events;however,some changes may
❑ 222 $300 $375 $375 $425 $400 $475 occur due to unavoidable circumstances.
❑ 223 $300 $375 $375 $425 $400 $475
❑ 224 $300 $375 $375 $425 $400 $475 Source Code:
0 225 $300 $375 $375 $425 $400 $475 CEWEB
❑ 226 $300 $375 $375 $425 $400 $475
0 227 $300 $375 1 $375 $425 $400 $475
0516 900008793 0 2016 National Safety Council
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