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HomeMy WebLinkAbout191247 10/27/2010 CITY OF CARMEL, INDIANA VENDOR: T362164 Page 1 of 1 ONE CIVIC SQUARE INDIANA STATE CHEMIST- PURDUE CHECK AMOUNT: $45.00 CARMEL, INDIANA 46032 175 SOUTH UNIVERSITY STREET o p WEST LAFAYETTE IN 46907 -2063 CHECK NUMBER: 191247 CHECK DATE: 10/27/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 N35567 45.00 ORGANIZATION MEMBER 2011 Indiana Pesticide Renewal. Application Instructions Public, Not For Hire Applicators and Registered Technicians PLEASE READ FOLLOW INSTRUCTIONS Questions regarding this Renewal Application should be directed to (765)-494- 1594: Step 1: On the enclosed license Renewal Application, circle "RENEW" for each applicator and/or registered technician listed who wishes to renew their credential. for 2011. Circle "ISO NOT RENEW" if an applicator or registered technician is not renewing. for 2011. Step2: Pleaseindicate "DO NOTRENEW'ifno one isrenewing. The Renewal Application must stM be returned to our office so our records can be updated. Step 3: Correct any inaccurate information (ie: names, addresses, etc...) by marking through the incorrect lines and adding the corrections. Step 4: Any certified applicator or registered technician whose name does not appear on the Renewal Application may be added by printing that person's name clearly at the bottom of this application or attach additional paper if necessary. if known, list the individual's old pesticide license number. Step 5: Fees are listed to the right on the application. Enclose a check or money order (credit card payments are not accepted) made payable to the Indiana State Chemist to cover the required fees as indicated on the Renewal Application. Add $45.00 for each additional applicator and/or registered technician that may have been added in Step 4. The renewal fees for all Public Applicators and Public Registered Technicians are waived (No fee required.) Step 6: Submit the Renewal Application and payment in the enclosed envelope before December 31, 2010 Those applications postmarked afterDecember3l, bylaw, require an additional 100 late fee penalty (multiply total renewal fee by 2). The 2011 credentials will be mailed during the week of December 13, 2010. Continuing Certification Hours (CCHs): If your certification had an expiration date of 12/31/ 10 and you had accumulated the required CCF the expiration date has been extended to the next five years. The expiration date will now read 12/31/15 on the renewal application. Your CC in that category have been reset back to zero. C.;CHS do not carry over to the next certification cycle. The CC H credits shown on the renewal application represent CCHs accumulated as of October 8, 2010. CC-H credits will continue to accumulate until December 31, 2010. Conference listings for CCHs, maybe obtained by using our web page a rww.isco.purdue.edu. On the main page click on "Pesticide" and then "Find CCH Conference Our web site can also be used to check the number of CC an individual has accumulated by selecting "Check My C:CF1s Page 1 2011 INDIANA PESTICIDE COMMERCIAL APPLICATOR RENEWAL APPLICATION BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY CARMEL.IN 46033 -1212 Current Phone: (317) 846 -7431 Ext. Current Fax: O Business e-mail: h� r ir1 4 "I'��l Submit the R ene wal A pplication in the enclosed envelope before December 31, 2010._ Certification in each category is valid for a five (5) year period. A license and technician registration is renewed each year prior to December 31. License Number= N35567 FEE $45.00 RENEW DO NOT RENEW Personal e-mail: ROBERT DAVID HIGGINS Category 3B 28 CCHs earned out of 20 required Category Expires 12/3/12012 otai Fee ©ue: $45.00 Submit the Renewal Application in the enclosed envelope before December 31, 2010. 1 hereby certify that the list being submitted is a true and accurate record of the current active employee working at this business location. I also acknowledge that failure to provide accurate information on this application form consititutes a violation of the Indiana Pesticide Use and Application Law (IC 15.3 -3.3.6 Section 65 (11)) berg Printed Name Job title of person signing Q a Signature Date FOR STATE CHEMIST OFFICE USE ONLY APPROVED DATE Check- No Amount Entersd_Under GN 30022 Posted Account PAL RT VOUCHER NO. WARRANT NO. Office of Indiana State Chemist ALLOWED 20 Purdue University IN SUM OF 175 S University Street West Lafayette, IN 47907 -2063 $45.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1207 N35567 43- 553.00 $45.00 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 Wednesday, October 20, 2010 Director, Brookshire Golf Club 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)) 10/20/10 N35567 Dues $45.00 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