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HomeMy WebLinkAbout163553 09/09/2008 CITY OF CARMEL, INDIANA VENDOR: 155699 Page 1 of 1 0 ONE CIVIC SQUARE I W E A CARMEL, INDIANA 46032 GARY D MERRIMAN- WPCMiSTM DEPT CHECK AMOUNT: $150.00 515 E WALLACE STREET CHECK NUMBER: 163553 FORT WAYNE IN 46803 CHECK DATE: 9/912008 DEPARTMENT A CCOU NT PO NUMBER INVOICE NUMBER AMOUNT DES CRIPTION 651 5023990 150.00 OTHER EXPENSES i I APPLICATION FOR VOLUNTARY COLLECTION SYSTEM OPERATION CERTIFICATION Administered by the Indiana Water Environment Association's Collection System Committee NOTE: A complete application forrn is required, including a $50.00 (non refundable) application fee for examinations; detailed employment information; supervisor's and applicant's signatures; and verification of your post high school educational qualifications attached. The application is to be typed, or neatly printed. Checks shall be payable to Ifl'EA. Failure to return a cornvleted application form by the final filing date will result in your ineligibility for that exarnination andforfeiture ofyour application fee. ALL EDUCATIONAND EXPERIENCE REQUIREMENTS MUST BEMETAND CLEARLY STATED. FAILURE TO MEET OR VERIFY EITHER OF THESE WILL RESULT IN INELIGIBILTY FOR THE EXAMINATION. All applications must be received prior to the 2nd Thursday in March for the April Examination and the 2ndThursday in September for the October Fxanunation. CERTIFICATION EXAMINATION APPLICATION, CLASS: CS-1 CS -II CS -ITT CS -IV (CIRCLE ONE) DATE: I. APPLICANT INFORMATIONwo n A. NAME ✓e j /7��{ !`OYL AJQt Last First Middle B. MAILfNG ADDRESS 7 70 W 85 7- i e A) Street 7 7 x 4 .4 ;/vie City State Zip Code County C. WORK PHONE NUMBER: (3 1 T 5' 7 y HOME PHONE NUMBER: (31 7 S CE 7 D y Area Code Number Area Code Number D. Have you previously applied for a Collection System Certificate NO (CIRCLE ONE) E. What certifications do you presently hold? List all that apply: Certification Number State Grade Class Water Treatment Water Distribution Municipal Wastewater Treatment Industrial Wastewater Treatment Wastewater Collection System ©<P t A- 1 Other II. EDUCATION AND TRAINING r a 'A High School: Name of School: G C /T 5 Location: 2 o n V r— t I/` Years Attended: t Date of Graduation: _C B. College: Name of School: I g d; q 4,L W eS/C n Location: 014o-; l Years Attended: Date of Graduation: C- Wrranj- 1.1 C4ro d C. NOTE: Attach verification of your post -high school educational qualifications. Copies of college transcripts or certificates of completion for courses related to wastewater treatment /collection provide acceptable proof of educational qualifications. You may list training courses, short courses, or other courses in the wastewater field that you have attended on Page 4. Include only post high school information III, WORK EXPERIENCE HISTORY List your present employment first then any additional employment. Give a detailed description of your collection system work experience as designated below- If you are not a fidl -time Collection Systems Operator, specify the average number of hours per week that are spent in the actual operation and maintenance of the collection system. NOTE: If you are applying for a Class III or IV examination clearly define AND document your "in-charge" experience and qualifications (supervision does not necessarily dictate "in- charge" experience). CURRENT EMPLOYMENT: II Current Employer: C i l 4 e 4 64, r wt �i t Dates From /Z /6 /C to Present Job Title: 5 e_jfl' CfieGk,,045 F Number j of Persons Supervised: 5 Job Description: f o 7G' 0 S' G7 S Sc�G i cI t+} h 7 r1 4 4 Q, c y s -t- o- y m SG 1`7 t'N r" !U� /8t fNro-r. "�:O;J: �•t o- M 4- v 4 4 e A r le Per Collection System Duties: n zc n x`� n.z n 5 e r r l a es in �te �5 `r e c l,.�nce •v'; �.o l ,da r =r• ,off c•.a a� --due r 1 Gr V 1 L KKYr'l i.V w-2 5 !t c. t; d .r+ a k 5 S' rn1 Classification of Wastewater Treatment Plant: Municipal I If III (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: ��77 S A Gallons Per Day (gpd) Supervisor'5Name: f 1 4 ✓ic j e Address: 7t;,u 3 1, 4 ✓e 5,0 ,1 g, e 1 rJ 9603 Phone No.: (5)7) 5 7 1 2C� 4 PRIOR EMPLOYMENT: Past Employer: u C11 „e ej f' Dates From 7 to 2s Job Title: t k e: _u r�o v4Nuiuber of Persons Supervised: Job Description: w -e n1 f Bn u_, 2 v 1.: 1. 1 n N� Ic�r. l �c n c r s-e r, e A,c 5 C /cz 1 ,z.e ke y 3 s: S r° Collection System tic Classification of Wastewater Treatment Plant: Municipal I II III CIO (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: III. WORK EXPERIENCE HISTORY (Continued) PRIOR EMPLOYMENT: Past Employer: Dates —From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification o f Wastewater Treatment Plant: Municipal I II III N (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: PRIOR EMPLOYMENT: Past Employer: Dates From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II III IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: IV. ADDITIONAL EDUCATION (Attach Copy of Completion Verification and /or Transcripts) 1. NAME/DESCRIPTIO OF COURSE: 0 or Co lee `(L Sa on) (Dates) (College Units or Class Hours) 2. NAME/DESCRIPTION OF COURSE: 6 Gva t we e f l; S {-r' S S S1� (Location) ates} (College Units or Class Hours) 3. N J AIviE/DESCRIPTION.OF COURSE: �G l "i ✓!2 a an c'n C 4 1 l-o r d e (Location) (Dates} (College Units or Class Haurs) 4. NAME/ DESCRIPTION OF COURSE: f �i�' nIlec�- ��l 1�1C, /�1�b�eeYa�S �C r F v�v �e5`� �t �a J (Location) (Dates) (College Units or Class Hours) V. SUPERVISOR'S VERIFICATION OF CURRENT EMPLOYMENT (to be completed by present Employer) 0 I hereb verify that the information contained in the current employment section of the application made by 00 u Q o be tr e and correct to the best of my knowledge and belief. Date Supery (soy's tgnature AP AwL. ROj O.A)6 SW-L Qo eclioo Sop fViSo ,r Title Printed Ftheu ndersigned, NATURE OF APPLICANT certify that I am the above applicant; that all statements made and information contained in this application are true to the best of my knowledge and belief, that I understand that any omissions or misrepresentations may result in ineligibility for the examination ap lied for. I also consent to a thorough investigation of my employment record and other qualification related act for the purpose of verification of my qualifications for the certificate for which I have applied. l CU ign re of App scant) (Date) Completed application form with check/money order for proper amount, and payable to I4VEA, should be returned to: Gary D. Merriman WPCM /STM, Department 515 East Wallace Street Fort Wayne, 1N 46803 NOTE: DUE DATE FOR APPLICATIONS, MARCH 13, 2008. FOR SPRING EXAM SEPTEMBER 11, 2008 FOR FALL EXAM LATE APPLICATIONS WILL NOT BE REVIEWED. r��f �Vrq�i���' G�� J� 1� 'Yv' 'S 'ff r y� IMT 11 59 M Qq <r 1 A, r �:Y r ..tea. r -�r�.• f Zw r -ti; 'tom: K .;y 7 z:: ?€r!_t.� d .�5.s,! --•177 l ..ra 1-�`1�- .,.j�.. f x F� r ss E !r, ...•7���1.^.t: r. "�,1 f C �•s,..k �s� x�f ,l: ;;;f;_•. �.J.1., d`, 1 r,�. i-�•,,,1 f.� r.� d i .'f� 4f r.,. Y.+ .v`: °rN t i a S `;':�d 9:In�:7SPSr rmm f C y r •r ``ti•::� ��J L��/ \J �1 4.:/ r f L�� LCD ;x 4 i .r C 4: 'fir. �j• ��lg h SS 7 ,4S 6 n 5 v� L, h� fi; £a .or.: w 4 .,.:.y;n. d k '�k r i. cr' "z, Y. i4 S�i x k 't..a,• 1 r f A r0 i ON l 4- r r at• +1 I ,':b• r 1,;!'t.. ,r �1, rrRt�! �L �j v... .'1 1 �S' X11 l' _.:1: ..•i: l i fF:f '4:, \rr -l" 4- rt '4 -r. f' :fix. _t 1 c�1s��:tp 3 t J �r 't.. J '.,r: ,F A�`4G` 14 n d n� F :`7 ,�.r .k .x -.%5 aA r t F`,e j C q :V .,y _0. .+f �.y�,,�� r d! r ta •r. ii v, .�•s•.. ,Fr r i1. 1E I �y y., �i .l'. :.t t. .5 Q., �f�n 4 t� h A.. _aS. �r "�iiJ l .,l l.iV t ..r_. _V ..:1 -�i... �:!'��r[••� r s.. b 1. t. !i .,f ..J. r. C t.7 -tree .l r- o,+ r.li.:"e'� t .lh i A .J.. t~ a;n' a S v. ll f.� r a d i,;.c:' f`;' a to p 1..: f �r �'v'i� r :-.tf Si'1 1 i �tSir .e`. i t� F 7 �q i/ e i f.d :.i tf ,..v r.Ef,.A d 'lt., s;eyi n/ .v' .,W.d;�.i� �..,.l.L :u- 1 i ai'nl-r {..�4...,tt._ \F r`•C.�.� f��,. \ry ..1, l.. �ca�, .ff ...r S.. d�?ti �ls ti. Jn :'Y% •�.1.:�.,., .�1. \S 4,; As t}. s.�,�la tC. $1',p :u,.: =•t"1t1\ta \l.✓ }•y t,, a� l' v�.� 4�� .i/ ��`t'._.� -7'< 1.'�• �4� ,t}.v ,����y%-, f x. f�fj";: ri •�j \"\�_''vi .eJ L� ti..•r .��wl� v _�3� r }:r ;��/"�3�..-- -v'-- -1i,• A.>�� --•`i- A��e: /L`l 1 is 4 �C. f /�a t. L •#F'�...` t APPLICATION FOR VOLUNTARY COLLECTION SYSTEM OPERATION CERTIFICATION Administered by the Indiana Water Environment Association's Collection System Committee NOTE: A complete application fora: is required, including a $50.00 (non- refundable) application fee for examinations; detailed employment information; supervisor's and applicant's signatures; and verification ofyour post high school educational qualifications attached The application is to be typed, or neatly printed. Checks shall be payable to IWEA. Failure to return a completed application form by the final filing date will result in your ineligibility for that examination andforfeiture ofyour application fee, ALL EDUCATIONAND EXPERIENCE REQUIREMENTSMUST BE METAND CLEARLY STATED. FAILURE TO MEET OR VERIFYEITHER OF THESE WILL RESULT ININELIGIBILTYFOR THE EXAMINATION. All applications must be received prior to the 2nd Thursday in March for the April Examination and the 211dThursday in September for the October Fsaminatinn. CERTIFICATION EXAMINATION APPLICATION, CLASS: CS -I CS -II CS -III CS -IV (CIRCLE ONE) DATE: 2- Z 0C> I. APPLICANT INFORMATION A. NAME Last Fi t Middle B. MAILING AD (O f Street e S 44 City State Zip Code County C. WORK PHONE NUMBER: 1 1- Z �o HOME PHONE NUMBER: 31 ­7 6 S L) Area Code Number Area Code Number D. Have you previously applied for a Collection System Certificate? ES NO (CIRCLE ONE) I?. What certifications do you presently hold? List all that apply: Certification Number State Grade Class Water Treatment Water Distribution Municipal Wastewater Treatment Industrial Wastewater Treatment Wastewater Collection System Other II. EDUCATION AND TRAINING n� A. High School: Name of School: e Location: Years Attended: Date of Graduation: NO I VA/ 0 B. College: Name of School: Location: Years Attended: Date of Graduation: C. NOTE: Attach verification of your post -high school„ educational qualifications. Copies of college transcripts or certificates of completion for courses related to wastewater treatment /collection provide acceptable proof of educational qualifications. You may list training courses, short courses, or other courses in the wastewater field that you have attended on Page 4. Include only post high school information III. WORK EXPERIENCE HISTORY List your present employment first then any additional employment. Give a detailed description of your collection system work experience as designated below. If you are not a f cll -time Collection Systems (perator, speck the average number of hours per week that are spent in the actual operation and maintenance of the collection system. NOTE: If you are applying for a_Class III or IV examination, clearly define AND document vour "in- charge" experience and qualifications (supervision does not necessarily dictate "in- charge" experience). CURRENT EMPLOYMENT: Current Employer: t l o C GJ M C i Dates From /J to Present Job Title: 4 l9�f�'1� Number of Persons Supervised: Job Description: 6 '[1?e f<n O Collection System Duties: dl� f� L ti� t� Classification of Wastewater Treatment Plant: Municipal I if I[I 1V (Circle One) Industrja I -SP A -SO A B D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: A' t 4 GOAL Address: 10/ V I&A t; Ae l?yZ Phone No.. PRIOR EMPLOYMENT: Past Employer: Dates From f to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II IIt IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: III. WORK EXPERIENCE HISTORY (Continued) PRIOR EMPLOYMENT: Past Employer: Dates From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II III IV (Circle One) Industrial I -SP A -SO A B C D Wastewater 'Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: PRIOR EMPLOYMENT: Past Employer: Dates From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II III IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: 1 IV. ADDITIONAL EDUCATION (Attach Copy of Completion Verification and /or Transcripts) 1. NAME/DESCRIPTIO COURSE: 3 "I- wL �r. C� l (Location) (Dates) (College Units or Class Hours) (Location (Dates) (College Units or Class Hours} 3. NAME/DESCRIPTION OF OURSE: /04 O c e C� tf �nriy. -4 e ­6 d7 (Location) (Dates) (College Units or Class Hours) 4. NAME/DESCRIPTION OF COURSE: (Location) (Dates) (College Units or Class Hours) V. SUPERVISOR'S VERIFICATION OF CURRENT EMPLOYMENT (to be completed by present Employer) I hereby r ify that the information contained in the current employment section of the application made by J' k '1�2e�t to be true and correct to the best of my knowledge and belief. H alo S? Date Supervisor s Signature P Dt. ��E Sc+r Title Printed VI. SIGNATURE OF APPLICANT I, the undersigned, certify that I am the above applicant; that all statements made and information contained in this application are true to the best of my knowledge and belief; that l understand that any omissions or misrepresentations may result in ineligibility for the examination applied for. I also consent to a thorough investigation of my employment record and other qualifications in rely a tiv es f e pu ose f verification of my lifications for the certificate for which I have applied. (Signature of Applicant (Date) Completed application form with checklmoney order for proper amount, and payable to IWEA, should be returned to: Gary D. Merrunan WPCM/STM Department 515 East Wallace Street Fort Wayne, IN 46803 NOTE: DUE DATE FOR APPLICATIONS, MARCH 13, 2008. FOR SPRING EXAM SEPTEMBER 11, 2008 FOR FALL EXAM LATE APPLICATIONS WILL NOT BE REVIEWED. n- sa.. .,ate- "s, _R:• 'k r 4 1 a E G 1 t t^ ;a Y's� -n 'j .w. .z ...,5 ,.s.,x.. .V. y^. 7, ea _P.. ..•v, a-, :rr �'r. 9�' t o+_. 1 k:�4... x .Y i f tL- T. T. :,,.1 .rf :+.s' d4 �h{ y.. .'r.4 xe MR r. r: tr. ',rte ,r 9 �3 .w. �r� ,ray, v ar v, r e':•..r c€ W �;r•..., 3+�•,r .,ur t+f ..�.,.G. `^Wr :,e J6 7•. t'ss+ l"'.. .f• t k.� rs. ..•S3?. 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Beck Has diligently and with merit completed 10 hours training in Occupational Safety and Health Standards Hosted by: DOWNEY SM INSURANCE Protecting Those Who Serves" APPLICATION FOR VOLUNTARY COLLECTION SYSTEM OPERATION CERTIFICATION Administered by the Indiana Water Environment Association's Collection S stem Committee NOTE:.4 complete application form is required, including a SM.00 (non refundable) applicationfee for exarninatioizs; detailed employment information; supervisor's and applicant's signatures; and verification of your post high school educational qualifications attached. The application is to be typed, or neatly printed Checks shall be payable to IWEA, Failure to return a completed application form by the final filing date will result in your ineligibility for that examination and forfelture of your application fee. ALL EDUC4TIONAND EXPERIENCE REQUIRE LENTS MUST BE MET AND CLEARLY STATED. FAILURE TO MEET OR VERIFYEITHER OF THESE WILL RESULT IN INELIGIBILTYFOR THE EXAMINATION. All applications must be received prior to the 2nd Thursday in March for the April Examination and the 2ndThursday in September for the October Examination. CERTIFICATION EXAMINATION APPLICATION, CLASS: CS -I. CS -II CS -III CS -IV (CIRCLE ONE) E.`' DATE: uq_.__ I. APPLICANT INFORMAT N A. NAME y l 1`° 1 y iii 1 V L Last 4 rst Middle B. MAILING ADDRESS i L 0 5 1 f`i toe f s 16r Ve Street J City State Zip Code County C. WORK PHONE NUMBER: f n l HOME PHONE NUMBER: (31 L 50 c._ i -31 Area Code Number Area Code Number D. Have you previously applied for a Collection System Certificate? Y` ES NO (CIRCLE ONE) E. What certifications do you presently hold? List all that apply: Certification Number State Grade Class Water Treatment. C l�� Water Distribution �J j Municipal Wastewater Treatment Industrial Wastewater Treatment Wastewater Collection System Ql `S Other II. EDUCATION AND TRAINING A. High School: Name of School: f ts+lt! 1 'LIN Location: Uc:.V I Years Attended Date of Graduation: B. College: Name of School: Location: Years Attended: Date of Graduation: C. NOTE: Attach verification of your nost -high school educational qualifications. Copies of college transcripts or certificates of completion for courses related to wastewater treatment /collection provide acceptable proof of educational qualifications. You may list training courses, short courses, or other courses in the wastewater field that you have attended on Page 4. Include only post high school information III. WORK EXPERIENCE HISTORY List your present employment first then any additional employment. Give a detailed description of your collection system work experience as designated below. If you are not a fill -time Collection Systems Operator, speck the average number of hours per week that are spent in the actual operation and maintenance of the collection system. NOTE; If you are applying for a Class III or IV examination clearly define AND document your "in- charge" experience and qualifications (supervision does not necessarily dictate "in-charge" experience). CURRENT EMPLOYMENT: 1 s Current Employer: i 4 01 Cu. P w,a A f a� S Dates From 4✓ to Present Job Title: :�Qw-4ri Cu 2C +o3a S" ii r Number of Persons Supervised: Job Description: 54pasvi Boa d akk a5p is 03 (00.'d•, C)AVIAtmel R r jt ,J. 't SQV,Q Colleciov p r Cute Gt war UdiE ekea t r G.NeA c J �'tJs'r sewer Cn.ni .1 �na.+halr be i,c e4wi. C� 5claa�u�. 4 �prytw :,ae tt:1]Qa' 4,' �fQ Ptt(i�f+'�pAfcLvi tCiCU�ty _iQ 5 S' N90 .4 .J [9 u�`.�C+S: ar• a► .i r;, ct c rvtierll u 6 J ;y�e;�� l:x rt? �k5. Collection System y d uties, ca5 0 cql� ea +0 it }uiz WVJ4 Ccile-A."xr 57Mtrr+ 'S A NC �eC� C GS b let ,Nc �1ra ie i+ 5' c -ere 5 (mot urcv�¢1 GE'et -t 4 `i:N• Gi,s S�v -•QS S" .v We' T cw r„ ec '�c+rennGN 40 56 i cs iNln`s h tk i '2Cl5 irl e' l}rizu 5 +rc Se wars Nc we' Classification of Wastewater Treatment Plant: Municipal I VV ri [II IV (Circle One) Indu trial I -SP A -SO A B C D Wastewater Treatment Plant Caapacity:� f"� Gallons Per Day (gpd) Supervisor's Name: l.t wv� re- Address: -30 se SW 4 1 1 0 a r w�a., !-TN L 4 (60 '3 9 Phone No.: (30) S I PRIOR EMPLOYMENT: Past Employer: Dates From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I If III IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: III. WORK EXPERIENCE HISTORY (Continued) PRIOR EMPLOYMENT: Past Employer: Dates —From 1 to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II III IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: PRIOR EMPLOYN4ENT: Past Employer: Dates From to Job Title: Number of Persons Supervised: Job Description: Collection System Duties: Classification of Wastewater Treatment Plant: Municipal I II ILI IV (Circle One) Industrial I -SP A -SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day (gpd) Supervisor's Name: Address: Phone No.: IV. ADDITIONAL EDUCATION (Attach Copy pp of Completion Verification and /or Transcripts) 1. NAMEMESCRIPTION OF COURSE: /Y��t 'r f• SQcc °s5 L'U'kv Nlc, ;.ie�5:E1 /5Z, C'w\e, -A- `3--06 4's CEi1 (Location) (Dates) (College Units or Class Hours) 2. NAM p E/DESCRIPTION O F COURSE: A.4 u ,je n c MQtist �.Ri, PCflJ sC Sk, V reign ,crc �,2,�tC Ill Q6U (Location) (Dates) (College Units or Class Hours) 3. NAM /DESCRIPT COURSE: C7 rd� t CWt( @,!J� U� tts}4ii[ �v� ec ;e�1 a 5 4 C \•TQ ON 11 LQ S !S�CfCM44 O la h'1 .t (Location) (Dates) (College Units or Class Hours) 4. NAME/DESCRI.PTIO c�., NOFCOURSE: W4 &r tl aew4r G,, -s r"Cj' -04J -f 1NR c�rJ i s: (Location) (Dates) (College Units or Class Hours) V. SUPERVISOR'S VERIFICATION OF CURRENT EMPLOYNIENT (to be completed by present Employer) I hereby verify that the informa #ion contained in the current employment section of the application made by r fit "Owuu to be true and correct to the best of my knowledge and belief. V S1 Date 7 0 Signature n ���P1�u9 Q /DP ��o u� �i�.0 V Q t/� Title Printed VL SIGNATURE OF APPLICANT I, the undersigned, certify that I am the above applicant; that all statements made and information contained in this application are true to the best of my knowledge and belief; that I understand that any omissions or misrepresentations may result in ineligibilit f�r t examinatio applied for. I also consent to a thorough investigation of my employment record and other qual eatio s ig lat activi es for t t he urpose of verification of my qualifications for the certificate for which I have applied. (Signature of plicant) (Date) Completed application form with check/money order for proper amount, and payable to IWEA, should be returned to: Gary D. Merriman WPCIVI/STM Department 515 East Wallace Street Fort Wayne, IN 46803 NOTE: DUE DATE FOR APPLICATIONS, MARCU 13, 2008, FOR SPRING EXAM SEPTEMBER 11, 2008 FOR FALL EXAM LATE APPLICATIONS WILL NOT BE REVIEWED. 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Q.f �s Z•5'1 P" 9 ���f�,��,� y =+xF� ,{e-��-:� /35 �N l� i �ss�.� 1 ���y�t�lrs�n�u�, nom'•... $ut'��r; i, �r, r�4���w �z`..,�,e i ri ;&i, i• t. ?4�! 4 L'. 3F� 4' q t� y �'�lr ,,;x a�. a t¢• .1 r� ��Sar wa,�¢,� ,a e=. z�:�' y e.. e, ti k' it a �>3, v 7� ;r r �e S q:d.. ie x i a ,ca+'- yf F 'r1i'E r 'L� a a� r J v '4 F -r r w, '�tY rr r y �+�..r s- w��,_�4 n a ^a r'�: k r Fo No. S gd 01 -S Statard Bo 1995) counts ACCOUNTS PAYABLE VOUCHER Fom No. 1995} TO ADDRESS Invoice Date Invoice Number Item Amount I 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 1 19 Signature Title 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. Officer Title Voucher No. Warrant No. ACCOUNTS PAYABLE DETAILED ACCOUNTS SANITATION DEPARTMENT ACCT. NO. CARMEL, INDIANA Favor Of C1 We�1 tTotal- Amount -of: voucher Deductions 0 1 6 54 O O .76YV.0 Amount of Warrant /SQ C) Month of 19 VOUCHER RECORD No Collection System Operation Plant Commercial General Undistributed Construction Depreciation Reserve Stock Accounts Merchandise Total Allowed Board Members Filed BOYCE FORMS SYSTEMS 1-800- 382 -8702 325