189404 08/31/2010 CITY OF CARMEL, INDIANA VENDOR: 175950 Page 1 of 1
0 ONE CIVIC SQUARE BRUCE KNOTT
CARMEL, INDIANA 46032 29393 N. HAYWORTH ROAD CHECK AMOUNT: $18.00
ATLANTA IN 46031
CHECK NUMBER: 189404
CHECK DATE: 8/31/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4343003 18.00 TRAVEL LODGING
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Please visit the conference web-sit at www.IndianaERC.com.to register using our simple and secure online form.
The website will have a detailed listing of all educational tracks including descriptions of each course, speaker
information and times for each class. You can also submit awards nominations, make your hotel reservation,
download maps and find new discounted parking options on the web site.
If you do not have access to the Internet, you may use the registration form below. Please note that it will take 2 -3
weeks to process your registration using this form.
Please print /type clearly in BLOCK LETTERS and complete all sections of the form. Use one form per registrant;
photocopy additional form(s) as needed. Early Registration ends July 26. There will also be an opportunity for on-
site registration August 11 14.
Bad a /Registrant Information: On -Site Emergency Information:
��c' ter
First Name Middle Initial Last Name Where will you be staying during the conference?
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Name as it is to appear on badge Name of person to contact in case of emergency/
t17/,) C ;c� n� Relationship to you
Title Department /Company F12 SOS_ y CJ CGS 7 a
Emergency Contact Phone (including area code]
Street Address City State /Zip
Meals:
Please indicate which meats you plan to attend,
Phone Fax Mobile including spouses and /or guests, to help provide an
d,(,, CQ1'�nai� //1, Qd;l yl� accurate meat count.
E -Mail Address Age Lunch: Thursday
jl 5z/rl^ Casino Night: Thursday
Your Department's Fire Marshal Phone Vendor Show Lunch: Friday
:7 Awards Banquet: Friday
Your Public Education Representatives) Phone Lunch: Saturday
do not plan to attend any.meals.
Are you affiliated with any organizations? Please list
P a y ment
1. Full Conference Registration Total /51d' Remit Payment To: Indiana Fire Chiefs As
Address: P.O. Box 364, Zionsville, IN 46077
2. Spouse Program Total Telephone: 1- 877 733 -1850 Fax: 317- 733 -4212
3. Single Day Registration Total E -Mail: rakefdindfirechiefs.org
4. Student Registration Total 0 Check Enclosed Check Number
5. Evening Functions Total 0 Credit Card (Visa Mastercard)
6. Additional Lunch Ticket Total
Indicate Total Amount Owed:
TOTAL PAYMENT DUE NOW: /so
Name
Signed: Card Type Card Number
Date: Expiration
Register and Pay Online at www.indianaERC.com
1.. Futt Conference Registration:
Includes all meals and programs. In addition to registering for the conference., you may.also sign up for the
August 11 golf outing. Please register foursdmes individually. (Check your preferences below. Early Registration
ends July 26.1 R
Early Full Conference w/ Golf: $205 Early Full Conference w /out Golf: $150
Late Full Conference w/ Golf: $255 Late Full Conference w /out Golf: $200
Conference Registration Total: Handicap (if registering for Golf)
2. Spouse Program Registration:
Includes Friday breakfast as well as Thursday and Friday daytime activities and evening events. Please provide all
contact info for your spouse below. (Check your preferences below. Early Registration ends July 26.)
Early Spouse Program w/ Golf: $155 Early Spouse Program w /out Golf: $110
Late Spouse Program w/ Golf: $195 Late Spouse Program w /out Golf: $150
Spouse Program Total: Handicap (if registering for Golf):
Spouse First /Last Name: Email: Cell Phone:
3. Single Day Registration: $85 ($100 after July 26)
Can't get away for the entire conference? Join us Thursday, Friday or Saturday for great activities and educational
sessions. Circle one choice:
THURSDAY FRIDAY SATURDAY
Single Day Registration Total:
i
4. NEW THIS YEAR Student Registration: $75
(Must present a student ID at check -in or letterhead stating that you are a current student from the school /establishment)
$75 includes all three days of conference workshops, vendor show and lunches. Student discount rate does not include
any evening functions. Tickets for evening functions can be purchased separately. Evening functions include a meal. f
Student Registration Total:
5. Evening Functions: $40 per function and person
Single tickets are available for individuals) wishing to attend the events below. Please note that these functions are
included with Full Conference, Spouse Program and Single Day Registrations. The following are for those who wish to
attend these events ONLY. Meals are included in the ticket price. Check your preferences or indicate quantity below.
Thursday Casino Night /Live Auction /Fundraiser $40 /person
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Friday night Awards Banquet with Daniel Cullen $40 /person i
Thursday Casino Night guest name(s) as it is to appear on name badge: i
i
Friday Awards Banquet guest names) as it is to appear on name badge: f
Evening Function Total:
b. Additional Lunch Tickets for Guests: $20
Quantity of Lunch Tickets Guest names) as it is to appear on name badge:
Lunch Ticket Total:
Register and Pay Online at www.IndianaERC.com
VOUCHER NO. WARRANT NO.
ALLOWED 20
Bruce Knott
IN SUM OF
$18.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1120 43- 430.03 $18.00 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 3 0 2010
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))
$18.00
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