307014 1/12/17 Q
CITY OF CARMEL, INDIANA VENDOR: 370124
ONE CIVIC SQUARE N C T R C CHECKAMOUNT: S********80.00*
CARMEL, INDIANA 46032 7 ELMWOOD DRIVE CHECK NUMBER: 307014
NEW CITY NY 10956 CHECK DATE: 01/12/17
DEPARTMENT ACCOUNT PO NUM R INVOICE NUMBER AMOUNT DESCRIPTION
1091 4341999 1 59095 80.00 OTHER PROFESSIONAL FE
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NCTRC
CTRS 7 Elmwood Drive
New City,NY 10956
NCTRC A �UAL MAINTENANCE call(845) 639-1439
fax(845) 639-1471
198% APPLICATION email nctrc@NCTRC.org
www.NCTRC.org
Nlame as i
Michell Yadon 59095
t apWars on ID Certification Nurnbcr
Cauxent Ed Ma&z Address 2336 3 Central Ave
Qty Indianapolis te iovince IN 46205 Courifty USA
Work 317-15 73-5245 Hasm Phone Cuwjwk am code)812-569-4134
Fax Number CuwhjA area cod 317 571-4136Addressyadonmichelle@gmail.com
Carmel Clay Parks& Rem tion
AgcaU dress s e ro Co 1235 Central Park Drive E. Carmel, IN
EMWU==: From 2 18 014 TO Present
1. Please check the box that best de sc s your employment status during the past year. _
@I work hill-time in TR/RT at least 30 hours per week). RF
OI work full-time at my agen y,but only part of this time is in TR/RT.
Number of hours pe r week in TR/RT J A N U 2011
OI work only part-time in RT(less then 30 hours per week).
Number of hours pe week in TR/RT
OI do not work in TR/RT. .
OI am not employed.
00ther
2 How would you best classify your p sition in TR/RT?(Select only the primary one): erapist/S M
I
I
Please enclose the Annual Mainten ce Fee of$80.00. If you are inactive,please submit the additional
required fees.
Payment Options:NCTRC accepti Credit Cards,Checks and Money Orders in US Funds.PIease fill out the
appropriate selection:
[CREDIT CARD 9CHEC OMONEY ORDER ^^i
[Visa [MasterCard OAmeric Express h r
Name as it appears on card: '1
Card Number.
Expiration Date:
By signing below I do hereby au ionize NCTRC to charge$ to the above
Visa/MasterCard/American Expikess Account
Signature(required):
Date:
PLEASE COMPLETE MAT MATORY SECTIONS ON THE BACK OF THIS FORM 4
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