186483 06/09/2010 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $330.48
INDIANAPOLIS IN 46204
CHECK NUMBER: 186483
CHECK DATE: 6/9/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 12982 330.48 MEDICAL EXAM FEES
INVOICE
E
.a Public Safety Medical Services
324 E. New York Street
Suite 300
W Indianapolis, IN 46204
G Carmel Police Department 1 CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 05/27/2010
-m. Invoice 00 -12982
Date Employee Description Amount Balance Due
05/17/10 Bickel Scott W. CMP $15.30 $15.30
CBC W /Dill And Plat 1214 $12,24
Lipid Panel $15.30 $15.3 0
Veni uncture Fee $3.06 $3.06
HIV 1 2 $13.26 $13.261
Quantiferon Tb Gold $51.00 $5i.00
Dunlap, Christo her T. CMP 15.30 $15.30
CBC W1Diff And Plat $12.24 $12.24
Lipid Panel $15.30 $15.3 0
Veni uncture Fee $3.06 106
HIV 1 2 $13.26 $13,
Quantiferon Tb Gold $51.00 $51.00
05121/10 Pitman Michael A. CMP $15.30 $15.30
CBC W /Dill And Plat $12.24 $12.24
Lipid Panel $15.30 $15.3 0
Veni uncture Fee $3.06 3.06
HIV 1 2 $13,26 13.26
Quantiferon Tb Gold $51.00 $51.00
Total Charges $330.48
Total Payments Balance Due $O.Oo $330.48
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: mind 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
Public Safety Medical Services Purchase Order No.
324 E. New York Street, Suite 300 Terms
Indianapolis, IN 46204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
5/27/10 12982 payment officer physicals 330.48
Total
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.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
P ublic Safety Medical Services IN SUM OF
324 E. New York street, Suite 300
Indianapolis, IN 46204
330.48
ON ACCOUNT OF APPROPRIATION FOR
police genera lfund
Board Members
P09 or DEPT. INVOICE NO. ACCT /TITLE AMOUNT I hereby certify that the attached invoice(s), or
1110 12982 407 --01 330.48 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
June 4 20 10
Signature
Chief of Police
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund