311202 05/09/17 •� CITY OF CARMEL, INDIANA VENDOR: 359233
ONE CIVIC SQUARE SAFE KIDS WORLDWIDE CHECK AMOUNT: S"""`"'85.00'
?� CARMEL, INDIANA 46032 C/o FES CHECK NUMBER: 311202
475 RIVERSIDE DRIVE,6TH FLOOR CHECK DATE: 05/09/17
«oa pO NEW YORK NY 10115
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
210 4357000 100370 GROSE 85.00 CHILD PSNGR SAFETY TR
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National Child Passenger Safety Certification Training Program Registration Form Page 1 of 1
National Child Passenger Safety Certification Training Program
Registration Form
Registration Type: Certification Course
Fee: $85
Course Information
Course ID: IN20170324405 Start Date: 6/19/2017
Registrant Contact Information
Name: Jim Grose SK ID: (762423)
E-mail: ]Grose@carmel.in.gov
Payment Information
Your registration will not be accepted without the check or complete purchase order information below. This
form must be filled out completely if paying by purchase order. If you are paying with a credit card, please
complete the registration process by paying online.
Any individual whose paper registration form is received ten or less business days before the scheduled start date
of a course must pay a $10 late fee. To avoid late fees, complete the registration process online with a
credit card. This can be done by going to view course registration history listed under the action items of your
profile.
** PRINT CLEARLY **
Payment Method:
❑Personal Check El Business Check
®Purchase Order ❑Money Order
Check/P.O. Number: U� 0 3
Amount on Check/P.O.: ) J
Issuing Agency: �;�{�tM z LAl /<C C
Billing Contact Name: '
O '_?v1
Billing Contact Phone: ( 3 12) S]/— ;
Billing Contact Email:
�C� ur�1U/J CU/L/Yle1.in.�Zt71/
Bill To Address: 3 U a 2 4
Ca1-Ale L
Please make checks payable to Safe Kids Worldwide and submit your payment and registration form to the
address below. Purchase orders can be faxed to 917-305-9876, attn: Safe Kids. If payment for multiple
registrations is included on the check or P.O., all registration forms must be submitted with the payment as a
group. The Safe Kids U.S. federal tax ID is 52-1627574.
Safe Kids
c/o PES
475 Riverside Drive, 6th Floor
New York, NY 10115
If you have any questions about this registration form, please contact customer service toll free at 877-366-8154.
https://ss106.cyzap.net/dzapps/dbzap.bin/apps/assess/webmembers/secure/custom?webid=sa... 4/3/2017