186775 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: 364285 Page 1 of 1
L ONE CIVIC SQUARE COMM ON FIRE PREVENTION AND CONTRA
CARMEL, INDIANA 46032 34 PERIMETER ROAD CHECK AMOUNT: $1,400.00
WINDSOR LOCKS CT 06096 CHECK NUMBER: 186775
CHECK DATE: 6/23/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 1,400.00 EXTERNAL INSTRUCT FEE
Student Application
A separate application is required for each course. Your ID Consist oWhe -First (3) Letters of your last name
Please print/type and mail /fax with payment to: and Last (4) number of your social security number
CFPC, 34 Perimeter Road, Windsor Locks, Cr 06096 -1069 ID Number .1 Example: John Adams SS 000-00-5555
Fax (860) 6541889 The new ID It will be ADA -5555
Last Name /J/ C LE As Chief of the
First Name WEE Fire Department or as Supervisor of the
organization,
Home Address y5 N q W a vs
I hereby authorize the above applicant to partici pate in the program beEow arid, therefore, understand that
the above -named individual will be covered by my organization's worker's .ompa ^cation Insurance while
participating in such training, and that the Commission on Fire Prevention and Conuol, its commissioners,
officers, agerts or employees shall rot be liable for any injuries sustained during such training.
finis applicant is mnsideied by my deparmen s standards w be physically and emotionally fit to perform
tirefiahtin e`r,lunars without spedal considerations, and where aglhcable, tr meet the 29 Cr,R 1914.
City �/}If0 r✓ s :andatd for the use of respirators (Self Centaired Breathi g Apparms).
Chief or Supervisor Signature
State rJ Zip
O S,Z No application hill be accepted without tuition, authorized signature and proof of prerequisite (if needed).
Proof included. Register me for the following course:
Phone (Home) Course Title
Work Course o
Cell 't u t -7 Date(s) Tuition
Method of Payment Payment is required at time of registra-
Pager tion. Faxes must include Credit Card or Purchase Order
Fire Department/Oiganization CA4Lr4E L Ft 9X be PT 1 -.I Check made payable to CFPC
Purchase Order
Entail ��rt x9_ G v%Ov, coM
L3VISA MasterCard Card
Check box if you would like to subscribe your e -mail address
to the CFPC listserve.
Card Holder's Name:
Are you 18 years of age or older? es ^I No
(No one under 18 is allowed to participate in hands -on programs) Card Holder's Signature: Exp. Date:
Student Application
A separate application is required for each course. Your ID Consist of the First (3) Letters of your bast name
Please printhype and mailffax with payment to: and Last (4) number of yoursocial security number
CFPC, 34 Perimeter Road Windsor Locks Cr 06096-1069 ID Number Example: John Adams SS a 000 -00 -5555
Fax (860) 654-1889 The new ID will be ADA -5555
Last Name CC P_ 11' As Chief of the
First Name r 5A
Fire Department or as Supervisor of the
V 2 EDEN w� organization.
Home Address Q t
I l ereby authorize tr:e above applicant to participate in the program below and, therefore, understand that
the above -named individual will he cevered by my organizat'ion's worker's coinGensation Insurance while
participating in such trairing, and [hat the Commission on Fire Prevention anc: Control, ius commisslaners,
cfficers, agents or employees shall not be liable ii any in}uries sustained during such training.
This applicant is considered by my dcpaiimen-; s standards to be physically and emotionally fit to pernorm
city CQ,QPAC L f' reigittiroeveiutionswithowspecial considerations, andwheie applicable, tomeel the 29Lrrt1910,134
standard (or the use of respirators (Seli- Coniained Breathing Apparatus).
Chief or Supervisor Signature
L
State Zip application w l be accepted without tuition, aumoozed signature and proof of prerequisite (if reeved).
T �J
QQ ^_i Proof included. Register me for the following course:
Phone (Home) 31'7 S d 2 SU 1/
I Course Title
work r(3 S I 4. (o b� Course Q G
Cell 7) �d Z Date(s) Tuition
Method of Payment Payment is required at time of registra-
Pager tion. Faxes must include Credit Card or Purchase Order
Fire Department/Organization Q lAi F; IRE QE P l Ch eck made payable to CFPC
J Purchase Order
Email
;_-,VISA MasterCard Card
Check box if you would like to subscribe your e -mail address
to the CFPC listserve.
Card Holder's Name:
Are you 18 years of age or older Yes No
(No one under 18 is allowed to participate in hands -on programs) Card Holder's Signature: Exp. Date:
Akh JA
Paw ft No w k sheop
The purpose of the IAFF -IAFC -ACE PFT certification program is to provide a fitness
trainer standard consistent with the health and fitness needs of the Fire Service throughout
the United States and Canada. The Peer Fitness
Trainer (PFT) program was created so interested
fire department personnel could obtain certification
in fitness- program design and implementation in
order to help their peers with their fitness programs
on a one -on -one basis and to help with the physical;
training of recruits. Those successfully passing the
certification exam will have demonstrated they pos-
sess the knowledge and skills required to design and
implement fitness programs, improve the wellness
and fitness of the uniformed members in their de-
partments, assist in the physical training of recruits,
and assist the broader community in achieving well-
ness. and fitness.
The class consists of a five -day PFT workshop to
d� assist the candidate in successfully achieving certi-
fication. The class must consist of a minimum of r
25 students or cancellation of the class is manda-
tory. The American Council on Exercise (ACE) is the certifying organization that awards the`��
IAFF /IAFC /ACE Peer Fitness Trainer Certification to candidates successfully passing the
certification exam. Chess hours: 40
Eligibility Requirements: In order to be eligible to take the PFT examination you must be a
y
firefighter, EMS provider, or employed by a fire department and involved in a fitness pro-
gram. Examination candidates must possess a valid CPR certification by the day of the ex-
amination. For additional information look on the IAFF website www.lAFF.org under
Programs Services> Health and Safety >Wellness and Fitness> Peer Fitness.
Class Materials: Workout Clothing, Bring All Study Materials.
Fee: $700.00 Per Person Includes Books, Class and Certification Test
Monday— Friday 0800 -1700 hrs For General and Lodging Information
Location: New Britain Fire Department Contact: Bill DeFord
Host at Central Connecticut State Univ. Cell: 860 -916 -0588
1615 Stanley Street Office: 860 -627 -6363 ext. 343 T
New Britain, CT 06051 t
(Location on campus TBD)
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Contact Inforniation and
Amf cation on Back ,a
VOUCHER NO. WARRANT NO,
CFPC ALLOWED 20
t try i� h /lcf/�� IN SUM OF
34 Perimeter Road
Windsor Locks, CT 06096
$1,400.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
QO# Dept. INVOICE NO. ACCT #ITITLE AMOUNT Board Members
1120 43- 570.04 $1,400.00 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
JUN 21 210
r�
f
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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: 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.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Regis. Fee Griffin Nicley $1,400.00
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