HomeMy WebLinkAbout189328 08/31/2010 CITY OF CARMEL, INDIANA VENDOR: 096000 Page 1 of 1
1 ONE CIVIC SQUARE FIRE DEPT SAFETY OFFICERS ASSOC"C�ECK AMOUNT: $1,210.00
CARMEL, INDIANA 46032 PO BOX 149
ASHLAND MA 01721 -0149 CHECK NUMBER: 189328
CHECK DATE: 8/31/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 24111 1,210.00 REGIS FEES
J4 11i. �1 ,r I rPURC ki i a� e f CERTIFICATE NO. 003120155 002 0
ORDER NUMBER
FEDERAL EXCISE -TAX EXEMPT 35- 60000972 24111
ONE CIVIC SQUARE CARMEL, INDIANA 46032 -2584 MBER MUST APPEAR ON INVOICES,
SLI
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997 VOUCHER. SHIPPING LABBEE DE LIVERY M EMO., PACKING LS AND ANY CORRESPOND EN
RCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO.
DESCRIPTION
81271201
FDSOA Carmel Fire Department
ENDOR SHIP 2 C ivic Square
TO
P.O. Box 149 Carmel, IN 46032
Ashland, MA 01729 (317) 571-2622
4FIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT
OUANTITV UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43- 670.04
2 Each Regisiter Conference $805.00 $1,210.00
Sub Total: $1,210.00
AD-
end Invoice TO: I
Carmel Fire Department
2' Civic Square
Carmel, IN 46032
PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Carmei Fire Department PAYMENT &1� 10.00
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS T
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
C VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED,
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THERE 1S AN UNOBLIGATED BALANCE IN
THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDE
SHIP REPAID.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED.
PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS.
THIS ORDER ISSUED IN COMPLIANCE WiTYq CHAPTER 99, ACTS 1945 TITLE
AND ACTS AMENDATORY T14EREOF AND SUPPLEMENT THERETO.
2 4 1 CLERK- TREASURER
IOCUMENT (CONTROL NO. VENDOR COPY
Reg istration Form (Register online at www.fdsoa.org)
FDSOA Annual Safety Forum Pre- Registration Required
NOTE Use one registration form per person photocopies accepted. Please return completed
form, with payment in U.S. funds, to FDSOA, P.O. Box 149, Ashland, MA 01721 -0149. Make
checks payable to FDSOA. Save time register online at: http: /www.fdsoa.org.
Name: -Y ID Nickname:
Title: Z_
Agen
Address:
City: State: Zip: V�5'0
Day Time Phone: s 7 7 2600 FAX: 3 7 i 7 S 7 f 26 5�`
Cell Phone: s /7 c j n Email: r./
Conference Registration Fees
Member Non Member Amount
Safety Forum Only $325.00 $425.00
Safety Forum ISO Academy $425.00 $525.00 E] Safety Forum HSO Academy $425.00 $525.00
ISO Academy Only $200.00 $300.00
HSO Academy Only $200.00 $300.00
(ISO Certification Exam 95.00 $195.00
HSO Certification Exam 95.00 $195.00
X FDSOA Individual Membership Dues (,loin now to take advantage of the member rate) 85.00
TOTAL AMOUNT DUE
Payment Information: (U.S. Funds, drawn on U.S. Bank)
Enclosed is a check payable to FDSOA C7Enclosed is an official Purchase Order
MasterCard Visa
Card Number: Expiration Date:
Card Holder Signature: Date:
Card Holder Name: (Please Print)
Cancellations: Cancellations must be made in writing and sent to FDSOA, P. O. Box 149, Ashland, MA
01721- -0149. if received 30 days prior, 75% of Forum Registration only will be refunded; 7 -29 days prior,
50% of Forum Registration only will be refunded. Less than 7 days, no refund is possible.
FDSOA Non -Profit Org.
P. O. Box 149 U.S. POSTAGE
Ashland, MA 01721-0149 PAID
Permit No. 125
Ashland, MA
Registration Fora (Register online at www.fdsoa.org)
FDSOA Annual Safety Forum Pre- Registration Required
NOTE: Use one registration form per person photocopies accepted. Please return completed
form, with payment in U.S. funds, to FDSOA, P.O. Box 149, Ashland, MA 01721-0149. Make
checks payable to FDSOA. Save time register online at: http: /www.fdsoa.org.
Name: =°c��. Nickname:
Title:
Agency:
Address:��-
City: State: Zip:
Day Time Phone: �s� FAX: 5
Cell Phone: Email:
Conference Registration Fees
Member Non Member Amount
Safety Forum Only $325.00 $425,00
IX Safety Forum ISO Academy $425.00 $525.00 ��s
❑Safety Forum HSO Academy $425.00 $525.00
ISO Academy Only $200.00 $300.00
HSO Academy Only $200.00 $300.00
ISO Certification Exam 95.00 $195.00 �.5
HSO Certification Exam 95.00 $195.00
XFDSOA Individual Membership Dues (Join now to take advantage of u,e member rate) 85.00 5 °Q
TOTAL AMOUNT DUE bos.
Payment Information: (U.S. Funds, drawn on U.S. Bank)
Enclosed is a check payable to FDSOA Enclosed is an official Purchase Order
MasterCard Visa
Card Number: Expiration Date:
Card Holder Signature: Date:
Card Holder Name: (Please Print)
Cancellations: Cancellations must be made in writing and sent to FDSOA, P. 0, Box 149, Ashland, MA
01721 -0149. If received 30 days prior, 75% of Forum Registration only will be refunded: 7 -29 days prior,
50% of Forum Registration only will be refunded. Less than 7 days, no refund is possible.
FDSOA Nan -Profit Org.
P. 0. Box 149 U.S. POSTAGE
Ashland, MA 01721 -0149 PAID
Permit No, 125
Ashland, MA
zUARr
r��FEry
o �v
�9 f� -AL O�
FDSOA Headquarters, P. O, Box 149, Ashland, MA 01721
Voice: 508 -881 -°3114 508 881 --1128 Email: membership @fdsoa.org
Incident Safety Officer Certification Application
Applicant shall meet requirements of NFPA 1521, 2008 Edition, Chapter 4, Section 4.5.1
Please type or print all information
Name: �?_4 T-: /fir` SS# Last 4 digits: �r0
Agency: r r-e, Y�� Rank: z
Department Type:_ Career Combination Volunteer Other
Address: V C ��z
City: �j State: Zip:
Day Time Phone: ,;Z�i G FAX: g 7 7 1 J��'
Cell Phone: 3�: `/�:�c� Email: �ab r6 n r� c�✓
Professional Experience (Required)
Agency r Dates Position
i r C f Z3 7
To Employer (Required)
Please verify the above information by signing below:
I verify that z r _�..`a has been involved in the emergency
services for a minimum of five years and meets the requirements of NFPA 1521, 2008 edition,
Chapter 4, Section 4.5.1
Print Name:
Required: Chief gr Chief Officer c
Signature:'
Required: Yhief or hief Officer
Rev. 01108
D� PAR r�Fyr
s ArsrY
ALI o�
1
O Fgc:' 5
FDSOA Headquarters, R O. Box 140, Ashland, MA 0`1721
Voice: 508- -881 -3114 508-881• -1128 0 Email: membership@afdsoa.org
Incident Safety Officer Certification Application
Applicant shall meet requirements of NFPA 1521, 2008 Edition, Chapter 4, Section 4.5.1
Please type or prink all information
Name: &n ✓G.S SS# Last 4 digits:
Agency: Ce i- wr j a° Rank:
Department Type:_ Career Combination Volunteer Other
Address: G
City: State: Zip: '7 1,1 2,7Z
Day Time Phone: 7 21- 7l FAX: 312 S7 J 26,'/ -5
Cell Phone: 31 ,53F 6 70 5 Email: CGS �c j US
Professional Experience (Required)
Agency Dates Position
r T Y t' "e L
To Employer (Required)�e
Please verify the above information by signing below:���
verify that has been involved in the emergency
services for a minimum of five (5) years and meets the requirements of NFPA 1521, 2008 edition,
Chapter 4, Section 4.5.1
Print Name:
Required: Chi o Chief Off' r r
Signature:
Require Chief or Chief Officer
Rev. 01108
VOUCHER-NO, WARRANT NO.
ALLOWED 20
FDSOA
IN SUM OF
P.O. Sox 149
Ashland, MA 01721
$1,210.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO, ACCT /TITLE AMOUNT Board Members
24111 43- 570.04 $1,210.00 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
AUG 302910
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))
FDSOA Conference $1,210.00
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