181161 01/13/2010 1,1 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH EERR
1,: ',pi CARMEL, INDIANA 46032 P 0 BOX 19383
t,FiE�K AMOUNT: $563.00
-A, 0 INDIANAPOLIS IN 46219
CHECK NUMBER: 181161
CHECK DATE: 1/13/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 253433 315.00 MEDICAL FEES
1091 4340700 253433 248.00 MEDICAL FEES
Community Occupational Health Services
Keeton P.O. Box 19383
Description /i4 -fci Q GJ l ee S Indianapolis, IN 46219
POD PorP 317 -355 -6335
Tax ID 35- 1955223 1
a� w.�, y7/00 -(0 V31/0 70o rays, `'v
�ARm J. r to g
6{)
Invoice °V
December 02, 2009
Bill to: Lynn Russell For: Carmel Clay Parks Recreation
Carmel Clay Parks Recreation 1 1/09
1411 E. 1 I6th St.
Carmel, IN 46032-
Invoice 253433
Proc Code Date Description Qty Charge Receipt Adjust Balance
30101 11/16/2009 Drug Screen Non N I DA 5 Panel 1.00 45.00 45.00
Alicia M Deckard Balance Due: 45.00
50101 11/05/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Oyke Duroglu Balance Due: 45.00
30101 11/17/20119 Drug Screen Non NI DA 5 Panel 1.00 45.00 45.00
Erin E Eckstein Balance Due: 45.00
80101 1 I/1 1/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Steven "1' Habig Balance Due: 45.00
11/10/2009 Review Questionnaire 1.00
1 1/ 10/2009 Respirator Fit Test 1.00 47.00 47.00
1 1/10/2009 Fitness To Wear Respirator Exam 1.00 72.00 72.00
94010 11 /10 /2009 Spirometry w/o Bronchodilator 1.00 59.00 59.00
Fredrick L Hagcmier Balance Due: 178.00
92551 11/11 /2009 Audiogranlwin Physical 1.00 25.00 25.00
William H Loveall Balance Due: 25,00
50101 11/17/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Eric R Mehl Balance Due: 45.00
301111 11/19/21)09 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Jodie B Ogle Balance Due: 45.00
00101 11/17/2009 Drug Screen Non N IDA 5 Panel 1.00 45.00 45.00
Invoice 253433 (continued) page 2
Elizabeth M Russell Balance Due: 45.00
S0101 11/07/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Theodore Simmons Balance Due: 45,00
invoice 253433 Balance Due: 563.00
PLEASE REMIT PAYMENT PROMPTLY. THAN{ YOU
Cat and return with payment
Please remit 563.00 to Community Occupational Health Services
P.O. Box 19383
Please place invoice number 253433 on check Indianapolis, IN 46219
Phone: 317- 355 -6335
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee Purchase Order No.
355031 Community Occupational Health Services Terms
P.O. Box 19383
Indianapolis, IN 46219
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s)) PO
248.00
12/2/09 253433 Pre- employment drug testing 2 2 44 8.00
12/2/09 253433 Pre- employment drug testing
Total 563.00
1 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
20
Clerk- Treasurer
Voucher No. Warrant No.
355031 Community Occupational Health Services Allowed 20
P.O. Box 19383
Indianapolis, IN 46219
In Sum of$
563.00
ON ACCOUNT OF APPROPRIATION FOR
rogram and
PO# or Board Members
INVOICE NO. ACCT #1TITLE AMOUNT
Dept
Oqi 48ita 253433 4340700 248.00 I hereby certify that the attached invoice(s), or
(O$ fe4$ 5 253433 4340700 315.00 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
7 -Jan 2010
4 IF 1/
77
Signature
563.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund