HomeMy WebLinkAbout325755 05/30/18 CITY OF CARMEL, INDIANA VENDOR: 371293
j; Pb ONE CIVIC SQUARE INDIANA STATE CHEMIST CHECK AMOUNT: $********45.00*
s CARMEL, INDIANA 46032 INDIANA STATE CHEMIST PURDUE UNIV. CHECK NUMBER: 325755
175 S.UNIVERSITY ST. CHECK DATE: 05/30/18
WEST LAFAYETTE IN 47907-2063
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 2018 PICKETT 45.00 ORGANIZATION & MEMBER
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
Vendor# 371293 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
INDIANA STATE CHEMIST IN SUM OF$ CITY OF CARMEL
INDIANA STATE CHEMIST PURDUE UNIV. An invoice orbill to be properly itemized mustshow:kind ofservice,where performed,dates service
175 S. UNIVERSITY ST. rendered,by whom,rates per day,number of hours,rate per hour,numberof units,price per unit,etc.
WEST LAFEYETTE, IN 47907-2063
Payee
$45.00
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Course 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
2018 R Pickett 43-553.00 $45.00 1 hereby certify that the attached invoice(s),or 5/20/18 2018 R Pickett R Pickett Dues $45.00
Dues Dues
1207 101 bill(s)is(are)true and correct and that the 1207 101
materials or services itemized thereon for
which charge is made were ordered and
received except
Monday, May 21,2018
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
Rev.09 n5 APPLICATION FOR INDIANA PESTICIDE CREDENTIALS Phone:765-494-1594
Print or Type All Information Fax:765-494-4331
I. Applicant: 11 rr I B#
a) Business Name Afod*5 6i rl? l7o!( 6&b ,/
b) Business Address 12.1 2 0 1S t'oo K Sh-cf, P K m,a ��l �/l 1-&0 3 Z
(Street,P.O.Box) V (City) (State) (Zip Code)
c) Business E-mail Address �;(�, e �-�� 14- 9- b J
(Physical location of business if P.O.Box is given)
d) Business Phone ,3/ '� - ��O �3/ Countyy�HOL'r"i
e) Individual's Name P CAQV ICS� I
(Last) / (Fnst) (MID
f) Last four(4)digits f y oc al Security# 6 Z
g) Signature Date J a l
h) ❑ Change of employment.No fee required if holding a license for the current license year.
H. Type of Credentials Requested:
Check all of the following that apply to this application request.
Issued to the business location listed above. (Include previously listed credential#if known) Annual Fee
a) M Pesticide Business License(Certificate oflnsurance required) $45.00
b) Cat. 12/Wood Destroying Pest Inspection Bus.License(Insurance required) 45.00
c) ❑ Restricted Use Pesticide Dealer Registration 45.00
Issued to the individual listed above. (Use a separate form for each individual)
d) For Hire Pesticide Applicator License OR Category 13 (Limited Certification) F# 45.00
e) El Not for Hire Pesticide Applicator License N# 45.00
f) ❑ Public Pesticide Applicator License PB# no fee required
g) HReg
Public Registered Technician(afully certified&licensedperson need not apply) PT# no fee required
h) istered Technician(a fully certif ed&licensed person need not apply for R7) RT# 45.00
i) ❑ Cat. 12/Wood Destroying Pest Inspection License WDI# 45.00
III. Fee Total: (Add all applicable fees and enter total here)S
IV. Reciprocity:
Out of state applicants requesting an Indiana license based on certification from your home state should enter home state
and certification from that state.
(State) (Certification#from that State)
V. Effective Date:
I request that these credentials be issued(check one):
Immediately(All credentials expire December 31st of the year of issuance)
Next January 1
VI. Payment
Mail checks payable to: Indiana State Chemist,along with completed form(s)
and certificate of insurance(if required)to: Office of Indiana State Chemist
Purdue University
175 S. University Street
West Lafayette,I7V 4 790 7-2063
FOR STATE CHEMIST OFFICE USE
Check# Amount Entered Under
Posted Account#