Loading...
HomeMy WebLinkAbout320129 12/21/17 , r CITY OF CARMEL, INDIANA VENDOR: 370124 e it ONE CIVIC SQUARE N C T R C CHECK AMOUNT: $********80.00* CARMEL, INDIANA 46032 7 ELMWOOD DRIVE CHECK NUMBER: 320129 NEW CITY NY 10956 CHECK DATE: 12/21/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1091 4341999 59095 80.00 OTHER PROFESSIONAL FE Voucher No. Warrant No. 370124 N C T R C Allowed 20 7 Elmwood Drive New City, NY 10956 In Sum of$ $ 80.00 ON ACCOUNT OF APPROPRIATION FOR 109 -Monon Center PO#or INVOICE NO. ACCT#/TITL AMOUNT Board Members Dept# 1091 59095 4341999 $ 80.00 1 hereby certify that the attached invoice(s), or 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 December 21, 2017 QWULLAI A) Signature $ 80.00 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund NCTRC CT R S 7 Elmwood Drive New City,NY 10956 NCTRC` ANNUAL MAINTENANCE call(845) 639-1439 fax(845) 639-1471 APPLICATION emailnctrc@NCTRC.org � p cwww.NCIRC.org Name as it appears on ID 1\A 01e_l I C S�CA 1 01llCertification Number Current Full Mailing Address ;)(:o Al (e ✓� ko(�. City ►qd t G{✓lGf Dd l I`S State/Pro-wince �N Zip/Postal Code -4 c9©a 3 Country lel Work Phone Cnclude area code) � � ?_ S / 3 S 6Home Phone_(include area code) 61 d "`2TG�—4 K M Fax Number(include area code) �)1 ? —5-7 J-6a.T+E-mail Address f(ZR . W1y1G cloy) � Cit(,"ge(c(q A n A en Address Ci State rovince Zi ostal Code Coun C 1pGt� i�(� C ,.►-, t� Employment From dTo / / Pro SC Y-1� (�D G3 1. Please check box that best describes your employment status during the past year: work full-time in TR/RT(at least 30 hours per week). ❑I work full-time at my agency,but only part of this time is in TR/RT. Number of hours per week in TR/RT ❑I work only part-time in TR/RT(less then 30 hours per week). Number of hours per week in TR/RT ❑I do not work in TR/RT. ❑I am not employed. ❑Other 2. How would you best classify your position in TR/RT?(Select only the primary one): ,-VW r6LQ pQc,),S a r Please enclose the Annual Maintenance Fee of$80.00.If you are inactive,please submit the additional required fees. Payment Options:NCTRC accepts Credit Cards,Checks and Money Orders in US Funds.Please fill out the appropriate selection: ❑CREDIT CARD CHECK ❑MONEY ORDER OVisa ❑MasterCard ❑American Express Name as it appears on card: Card Number: Expiration Date: By signing below I do hereby authorize NCTRC to charge$ to the above Visa/MasterCard/American Express Account Signature (required): Date: j c�- /l/ �. PLEASE COMPLETE MANDATORY SECTIONS ON THE BACK OF THIS FORM 4 Retired 0816 ELIGIBILITY QUESTIONS&DECLARATION Mandatory Sections:Please complete all sections on this page for your application to be reviewed. ELIGIBILITY QUESTIONS: Please complete the following questions.A"YES"response to any of the questions posted below requires supporting documentation relevant to your response.NCTRC must be notified immediately if your response to any of the following questions changes during the period of your active certification. 1.Do you have a disabling condition or addiction to any substance that could im air com etent and objective professional perfor- mance of therapeutic recreation services and/or jeopardize public health and safety? C 2.At any time,have you been subject to an investigation or disciplinary action by a health care organization,professional association, governmental entity or regulatory or licensing agency or authority? 3.Have you ever been convicted,found or entered a plea of guilty or nolo contendere,or are you presently being*investigated or charged with any felony or misdemeanor directly relating to therapeutic recreation services or public health and safety? Questions#2 and#3 include,but are not limited to investigations or disciplinary actions by an employer,state or federal licensing agen- cy,and/or any crimes involving violence,rape,assault,sexual abuse,use or threatened use of a weapon,and/or the prohibited sale,dis- tribution or possession of a controlled substance.On an attached sheet of paper you must identify all investigations,allegations,charges and outcomes.Attach documentation if available.Note:if you are currently imprisoned,on probation or parole or a case is being ap- pealed,NCTRC will deny certification or recertification until 3 years following the exhaustion of your appeal,completion of probation or parole,or final release from imprisonment,whichever is later. DECLARATIONS-NCTRC PROCESSING AGREEMENT: NCTRC agrees to process your application subject to your agreement to the following terms and conditions. 1. To be bound by and in compliance with all NCTRC Certification Standards and rules relating to eligibility,renewal and recertification, including,but not limited to,payment of applicable fees,demonstration of educational and experiential requirements,satisfaction of an- hual maintenance and recertification requirements,compliance with the NCTRC Grounds for Sanctions and other standards,and com- pliance with all NCTRC documentation and reporting requirements,as may be revised from time to time. 2. To authorize NCTRC to disclose,publish and/or release,in the sole discretion of NCTRC,any information regarding your certifica- tion or recertification application or status and any final or pending disciplinary decisions to state licensing boards or agencies,other health-care organizations,professional associations,employers or the public. 3. To hold NCTRC harmless and to waive,release and exonerate NCTRC,its officers,directors,employees,committee members,and agents from any claims that you may have against NCTRC arising out of NCTRC's review of your application,or eligibility for certifica- tion,renewal,recertification or reinstatement,conduct of the examination,or issuance of a sanction or other decision. 4. To only provide information in your application to NCTRC that is true and accurate to the best of your knowledge.You agree to rev- ocation or other limitation of your certification,if granted,should any statement made on this application or hereafter supplied to NCTRC is found to be false or inaccurate or if you violate any of the standards,rules or regulations of NCTRC. 5. To abide by the following testing conditions: A. NCTRC reserves the right to refuse admission to any NCTRC examination if you do not have the proper identification,or if administration has begun.If you are refused admission for any of these reasons or fail to appear at the test site,you will not be enti- tled to a refund or deferral of the application or examination fees.During the exam,the use of scratch paper,calculators,or reference to textbooks or notes is prohibited and you are not allowed to remove any exam materials from the administration room. B. NCTRC's examinations are only offered to individuals who are seeking NCTRC certification or recertification,and for no other purpose. NCTRC's exams and individual questions are copyrightrotected and highly confidential trade secrets. Any disclosure or reconstruction of test questions and content shall be'a violation ofNCTRCrules and subject to damages including,but not limited to,the cost of replacing the compromised question(s)and reconstruction of the exam,if advisable in the discretion of NCTRC. C. Proctors are authorized to maintain a secure and proper test administration.You may not communicate with other examinees during the examination.Any irregular,disruptive,inappropriate or suspected cheating behavior by you may result in your relocation or removal from the examination site and/or a refusal to release your examination scores;in such event,your examination fees will not be refunded or deferred. SIGNATURE:By signing,I acknowledge and affirm that I have carefully read and understand NCTRC's standards,rules and require- ments and that I agree to abide by these terms and to be bound by all of the provisions of the Declarations above. PRINTED NAME:M L G u c+ [e ici.A012 _SIGNATURE: CONFIDENTIALITY RELEASE (Opdona4f I agree that NCTRC may release my name and any contact information on record with NCTRC to individuals and/or organizations for educational and/or research purposes.By signing this section,I understand that my name and address will be released on mailing labels requested by organizations sponsoring educational programs,conferences,and special research Stu -e Applicant Signature Date