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Home My WebLink About186875 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: 360375 Page 1 of 1 ONE CIVIC SQUARE INDIANA PROFESSIONAL LICENSING 0 CHECK AMOUNT: $200.00 CARMEL, INDIANA 46032 402 W WASHINGTON ST ROOM W072 INDPLS IN 46204 CHECK NUMBER: 186875 CHECK DATE: 6/23/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4355300 060110 200.00 ORGANIZATION MEMBER Indiana Professional Licensing Agency We work to State Board of Registration for Professional Engineers keep you working 402 W. Washington St. Room W072 p Indianapolis, IN 46204 i Professional Licensing Agency Gary Robert Duncan, Jr. 11034 Palatka Court Indianapolis IN 46236 To renew by m ail please return this entire page to the address above after answering all questions on the form. Be sure to enclose your renewal fee of $100.00. Checks should be payable to: "Indiana Professional Licensing Agency." ENGINEER RENEWAL FORM License Number pate Due Renewal Fee. o PE19900146 07/31/2010 $100.00 cc Gary Robert Duncan, Jr• 1.) Since your last renewal, has any professional license, certificate, registration, CL 11034 Palatka Court or permit you hold or have held been disciplined or are formal charges pending? YES NO Q Indianapolis IN 46236 2.) Since your renewal, have you been denied a license, certificate, m registration or permit in any state? YES NO Mail to: 3.) Since your last renewal, have you been convicted of or pled guilty to a violation Indiana Professional Licensing Agency of a federal or slate law or are criminal charges pending? YES NO 402 W. Washington St., Rm. V1' -072 Indianapolis, IN 46204 J I hereby swear or af£vm under the penall ies of perjury that the information provided here is trot end cortecl to the bell of my i0., knowledge. C S rra e A Ic Date Sieved: 'II 7 JW 2,610 Enter E -mail Address: Change of Address: U rme L v IF YOU ANSWERED "YES" to any of the questions above, you must provide a signed statement that explains all the related details. You mast include the violation, location, date, and disposition. Letters from Attorneys, insurance companies and/or court documents are not acceptable lli hell cif yow statement howeveI they may be irrciudcd with youi stzacii ent. Bo surc to w;.itc you na Iric and license number on all documents submitted with your renewal. ONLINE RENEWAL INFORMATION: The Login ID is your license number. The password is your social security You can update your address and other demographic information during the renewal or any other time by logging in to your records online. Renew online at www.pla.in.gov use License Express option. IMPORTANT RENEWAL INFORMATION: A $50.00 penalty fee will be assessed in addition to the renewal fee if your renewal is renewed after July 31, 2010. NAME CHANGE: Name change requests must be made in writing include a copy of a legal name change document (marriage license, divorce decree, or other Court Order establishing legal name) and mail to the address above. Be sure to include your licensek CONTINUING EDUCATION: Rules are currently pending which would implement continuing education requirements for renewal of your professional engineering license. Should these rules go into effect, you will be required to show proof of the hours earned for the next renewal cycle in 2012. Please go to our web site ww,v.pla.in.pov to get more information If you have questions: please contact us by email at plal0(apla.in.eov or by phone at (317) 234 -3022. During renewals, our phones can be very busy and it might be a long wait. India:la Professional Licensing Agency We work to State Board of Registration for Professional Engineers 0 keep you working 402 W. Washington St. Room W072 Indianapolis, IN 46204 iPLA Professional Licensing Agency Nicholas Joseph Redden 7219 West 75 South Lafayette IN 47909 -9263 To renew by mail please return this entire page to the address above after answering all questions on the form. Be sure to enclose your renewal fee of $100.00. Checks should be payable to: "Indiana Professional Licensing Agency." ENGINEER RENEWAL FORM License Number Date Due Renewal Fee C o PE60890306 07/3112010 $100.00 Nicholas Joseph Redden 1.) Since your last renewal, has any professional license, certificate, registration, a, 7219 West 75 South or permit you hold or have held been disciplined or are formal charges pending? YES NO Lafayette IN 47909 -9263 2.) Since your last renewal, have you been denied a license, certificate, registration or permit in any state? YES NO Mail to: 3.) Since your last renewal, have you been convicted of or pled guilty to a violation Indiana Professional Licensing Agency of a federal or state law or are criminal charges pending? YES NO 402 W. Washington St., Rm. W -072 J lndianapotis, IN 46204 1 hereby swear or aRam under the penahks of peryury that the information provided here is true and correct to the best of my to knowledge. C Siamtwe of Amlicant: Date Sierxd: 'C C Palm E -mail Address: Change ofAddrm IF YOU ANSWERED "YES" to any of the questions above, you must provide a signed statement that explains all the related details. You must include the violation, location, date, and disposition. Letters from Attorneys, insurance companies and/or court documents are not acceptable in lieu of your statement however they may be included with your statement. Be sure to Ante your name w.d license number on all documents submitted with your renewal. ONLINE RENEWAL INFORMATION: The Login ID is your license number. The password is your social security You can update your address and other demographic information during the renewal or any other time by logging in to your records online. Renew online at www.ala,in,gov use License Express option. IMPORTANT RENEWAL INFORMATION: A $50.00 penalty fee will be assessed in addition to the renewal fee if your renewal is renewed after July 31, 201.0, NAME CHANGE: Name change requests must be made in writing include a copy of a legal name change document (marriage license, divorce decree, or other Court Order establishing legal name) and mail to the address above. Be sure to include your license CONTINUING EDUCATION: Rules are currently pending which would implement continuing education requirements for renewal of your professional engineering license. Should these rules go into effect, you will be required to show proof of the hours earned for the next renewal cycle in 2012. Please go to our web site www.nla.in. %ov to get more information If you have questions: please contact us by email at plal0(a or by phone at (317) 234 -3022. During renewals, our phones can be very busy and it might be a long wait. Rrescrihed by State Board of Accounts City Form No. 261 )Rev. 1995) ACCOUNTS PAYABLE VOUCHER 1 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 Indiana Professional Licensing Agency Purchase Order No, 402 W. Washington St. Rm. W -072 Terms Lafayette, IN 47909 -9263 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 09/09/09 n/a Gary Duncan P.E. license renewal $100.00 n/a Nick Redden P.E. license renewal $100.00 Total $mn nn 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 Indiana Professional Licensing Agency IN SUM OF 402 W. Washington St. Rm. W -072 Lafayette, IN 47909 -9263 $200.00 ON ACCOUNT OF APPROPRIATION FOR Department of Engineering Board Members INVOICE NO ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 6/01/10 EN 34355300 $200.00 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 0 21 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund