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HomeMy WebLinkAbout307175 1/20/17 (9, ) CITY OF CARMEL, INDIANA VENDOR: 365721 CHECK AMOUNT: S*******806.23*ONE CIVIC SQUARE MIKE DELONGCARMEL, INDIANA 46032 C/O CFD CHECK NUMBER: 307175 CHECK DATE: 01/20/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4128000 806.23 TUITION REIMBURSEMENT k / 0 0 � k � k § w # q O ° n CY n m \ q 9 m / k / O C. a ¥ \ k D § > E 0 � O D / § \ K \ CD m 7 § © *k & ® -4 2 k 2 7 > -n O ; $ 0 O / / | � S z J a i g LT - r- E 0 § 2 ƒ c 0 { CD i gƒ E 2 J k -nx ` ® § ƒ - \ E § / f 2 0 -. ( 2 CL - a § E . 7 / / k § \ ) % 2 o f g & � 2 E » E \ k ƒ CL / / w C \ / f § CD ± ) 7 | � • - � Q � f 7 K« § \ C q § < (_ CL ° \ ) \ ƒ ) K # k .« § 2 � $ § / 0 ( _ o k ° 0 \ k -6 0 Z / Gn 0 ii § k g cr 0R m \( G \ 7 -n® � §o ) c ° � ��r \ \ \ / . E 2 \ ƒ M G CD 9/ co/ § g ] $ \ ) fc c (n C) ¥ C m m z / 73 -CW Cl)� m CL - ) / \ f ) ] \ # E , & \ § E 2 J a 7 $ 0 < CF) § % ) ¥ / Delong Tuition Reimbursement Class Credit Hours Cost per Credit Hour Total NRSG 201 Complex Med-Surg 4 $ 135.15 $ 540.60 NRSG 200 Complex Med-Sur 3 $ 135.15 $ 405.45 Book $ 61.74 TOTAL CLASS COST $ 1,007.79 Allowed Reimbursement 80% TOTAL TO BE REIMBURSED $ 806.23 TUITION IS$135.15 PER HOUR LAWNCE CAMPUS BKS FAIRBANKS CTR FOR HEALTH PROF 9301 E 59TH STREET 317-921-4693 ww omytechsnop.com ` i 1067mgr4fheg.follett.com ITEM Q'`J...__ PRICE TOTAL. € New NRSG 201 Kit *revised 2015* K2 016386531 1 $57.70 $57.70T l Sub notal 57.70 Tax 4,04 Total $61.14 Credit Card Visa 61.74 Acct# ************4159 Auth# 09558E 3 IN 7.0 @ 7.0000 4.04 Items ?urcnased: 1 3 Items Retarned: 0 !illl 11111111111111 IN 11111 11111111;1II II lill 11111111111 * x787684035581 * t City Of Carmel Tuition Reimbursement Application Form Part I (to be completed by employee) (Please print. Submit completed form to Department Headrip for to commencement of course.) Employee Name Michael DeLong Department Fire SSN Hire Date 3/6/1999 Educational Institution* Ivy Tech Community College Name of course** NRSG 201 Complex Med-Surg NSG for ASN Clinical Credit Hours 4' Starting Date of Course(month/day/year) 8/22/2016 By signing below,I signify that I understand the following: • The tuition reimbursement program is subject to the terms of Carmel City Code, Section 2-58. • To receive reimbursement for tuition, I must submit evidence of payment for the course and a copy of my final grade. To receive reimbursement for books, I must submit an original itemized receipt or other proof of purchase that links these books to this particular course. • If I leave City of Carmel employment sooner than one (1) year after the end of this course, I will repay the City in full for its tuition and book reimbursements for this course. • The tax status of reimbursement p yments is subject to federal law,which may change from time to time. 01 Employee Signature Date 6/24/2016 Part II(to be completed by Department Head) — (Submit to Human Resources) By signing below, I certify that the applicant will have been employed full-time by the City for at least one(1) year prior to the commencement of the course, and has not been subject to a disciplinary probation, suspension or demotion within 90 days prm to the beginning of the course. The final claim will be paid from my department's budget,subject to qie rms of Section 2= 9 f Carn 1 City Code. .G Department Head Signature Date Part III (to be complete by Director of Human Resources) Final Approval �`'�''"�'^"'� — Date 4 f 3� If denied,reason for denial * The tuition reimbursement program covers only full-semester courses offered through a degree-granting institution accredited by the North Central Association of Colleges and Schools or an equivalent regional accreditor. ** An application will not be considered complete unless a course description from the school's literature is attached. City Of Carmel Tuition Reimbursement Application Form Part I (to be completed by employee) (Please print. Submit completed form to Department Head prior to commencement of course.) Employee Name Michael DeLong Department Fire SSN Hire Date 3/6/1999 Educational Institution* Ivy Tech Community College Name of Course** NRSG 200 Complex Med-Surg NSG for ASN_ Credit Hours 3.0 Starting Date of Course(month/day/year) 8/22/2016 By signing below,I signify that I understand the following: • The tuition reimbursement program is subject to the terms of Carmel City Code, Section 2-58. • To receive reimbursement for tuition, I must submit evidence of payment for the course and a copy of my final grade. To receive reimbursement for books, I must submit an original itemized receipt or other proof of purchase that links these books to this particular course. • If I leave City of Carmel employment sooner than one (1) year after the end of this course, I will repay the City in full for its tuition and book reimbursements for this course. • The tax status ofreimburseme t payments is subject to federal law,which may change from time to time. Employee Signature;77 �') `� f./`f Date 6/24/2016 Part II(to be completed by Department Head) (Submit to Human Resources) By signing below, I certify that the applicant will have been employed full-time by the City for at least one(1) year prior to the commencement of the course,and has not been subject to a disciplinary probation,suspension or demotion within 90 days prior t he beginning of the course. The final claim will be paid from my department's budget,subject to the t m of Section 2-58 0 C mel C' Code. Department Head Signature Date Part III(to be completed by Director of Human Resources) Final Approval Date (1/3-01// If denied,reason for denial * The tuition reimbursement program covers only full-semester courses offered through a degree-granting institution accredited by the North Central Association of Colleges and Schools or an equivalent regional acereditor. ** An application will not be considered complete unless a course description from the school's literature is attached. Statement Term Due Date Amount Due IVY TECH Date COMMUNITY C01 I FGE 07/26/2016 Fall 2016 08/19/2016 $ 1,533.35 (201620) 50 West Fall Creek Pkwy N. Dr Indianapolis, IN 46208 317.921.4800 Michael DeLong http://www.ivytech.edu Noble Belfry Dr Noblesville, IN 46060-6079 Student ID: C05192874 Fall 2016(201620) Schedule CRN SUBJ CRSE SEC COURSE TITLE CREDS DAYS START/STOP BUILD ROOM 24328 NRSG 200 C1 H Complex Med-Sur 3.00 T 1200-0250pm LAWFB F214 24418 NRSG 208 A3H Practice Issues 2.00 TR 0300-0450pm LAWFB F211 38209 NRSG 201 C1H Complex Med-Sur 4.00 MWF 0630-0630pm LAWFB NOROOM Total Credit Hours:9.00 Account Summary Charges Credits/Anticipated Credits H1-In State Tuition 1000.35 H1-NCLEX Review 325.00 1­11-Nurse Program Fee 125.00 H1-Technology Fee 60.00 N1-Capstone Fee 23.00 Total Charges: $ 1,533.35 Total Credits/Anticipated Credits: $0.00 Previous Balance Current Term Balance Amount Due Future Balance $0.00 $1,533.35 $ 1,533.35 $0.00 Financial Aid Receipt Reprint Request Today's Date: (4 C#: G U S t 7 `l Item to return: 15-' ��' f co ri Is LF x -AX f Estimated Purchase/Receipt Date: Customer Name: Phone Number: 4 13 y9 Comments: G Cf-J- -9 Y15-9 CARP Instructions: U Store: 1067 Page: 1 Follett Higher Education Group Date: 8/31/2016 Time: 4:55PM Customer Transaction Reprint Customer Name: Customer M 0 Register: 404 SalesPerson 1: 0 Tx#: 3164 Drawer: 1 SalesPerson 2: 0 Date: 8/25/2016 Associate:172855 SalesPerson 3: 0 Time: 11:44AM SKU Description Quantity Price Extended 015036763 NCLEX-RN PassPoint 1 199.99 199.99 IN 7.0 @ 1 14.00 14.00 Total Due: 213.99 Visa 213.99 Transaction Comments: LAWRENCE CAMPUS BKS CARD TYPE: Visa ACCT # : ************4159 AUTH CODE: 02807B $213.99 ,Signature.... .. ... . . . . . . . . . .. . . 1�— I AGREE TO PAY ABOVE TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT, Trn 3164 1067 404 2 8/25/16 11:44 Ivy Tech Community College - Official Grades Page 1 of 2 1 Lyn 1:10 on C05192874 Michael DeLong Fall 2016 Ivy Tech Community College - Official Dec 27, 2016 04:47 pm Grades Student Information Current Program Associate of Science Level: Undergraduate Program: Indianapolis Nursing AS Admit Term: Fall 2015 Admit Type: Continuing New Degree Catalog Term: Fall 2015 College: Ivy Tech Campus: Indianapolis Major: Nursing Major Concentration: Nursing Paramedic to AN Academic Standing: Good Standing Undergraduate Course work CRN Subject Course Section Course Campus Final Attempted Earned Title Grade GPA Quality Hours Points 24328 NRSG 200 CIH Complex Med- Indianapolis- B Surg NSG for Lawrence 3.000 3.000 3.000 9.00 ASN 38209 NRSG 201 CIH Complex Med- Indianapolis- A Sung Nsg ASN Lawrence 4.000 4.000 4.000 16.00 Clini 24418 NRSG 208 A3H Practice Issues Indianapolis- A Assoc Degree Lawrence 2.000 2.000 2.000 8.00 Undergraduate Summary Attempted Earned GPA Hours Quality Points GPA Current Term: 9.000 9.000 9.000 33.00 3.667 Cumulative: 43.000 43.000 43.000 155.00 3.605 Transfer: 55.000 55.000 0.000 0.00 0.000 Overall: 98.000 98.000 43.000 155.00 3.605 Select another Term RELEASE: 8.7.1 https://banprd-ssb.ivytech.eduBANNER/bwskogrd.P_ViewGrde 12/27/2016 Payment History Page 1 of 1 IM- Bill+Payment Header Logged in as:Michael DeLong Payment History Payment History for Michael DeLong(Student Accounts) To sort,click on the desired column header. Description Date Code Amount($) ZO-Web Payment 11/28/16 _. WEBP 138.00 ZO-Web Payment 11/28/16 WEBP -138.00 ZO-Web Payment 11/26/16 WEBP -138.00 Direct Fed Unsubsidized Loan 10/3/16 ZLLB 138.00' Direct Fed Unsubsidized Loan 9/11/16 ZLLB -3,292.00 FE-2 Bill+payment Footer UCommnn 6.51 B9-"—N 650 +fe � 0199]-1616 TacM1NN In—So—Inc.AN rgh reserveE.ITA!Tov'.M1Ner Prhxy Po1cy ghIW •N..nrM v https:Hsecure.touchnet.net/C20006—tsa/web/display—historyjsp 12/28/2016