HomeMy WebLinkAbout157103 03/05/2008 CITY OF CARMEL, INDIANA VENDOR: 360927 Page 1 of 1
0 ONE CIVIC SQUARE INDEPENDENT HEALTH CLUB ASSOCI CHECK AMOUNT: $99.00
CARMEL, INDIANA 46032 40010TH ST NW
NEW BRIGHTON MN 55112 CHECK NUMBER: 157103
CHECK DATE: 3/5/2008
DEPARTMENT ACCO PO NUM INVOICE NUMBER AMOUNT DESCRIPTION
1047 4355300 99.00 ORGANIZATION MEMBER
Independent Health Club Association
(NIHCA) 7F IVED
A non profit Corporation 8 200 8
Activation Form
Club Name t n.., Ge n+*_f c_- CAr+r- t kr k
Address X2.35' -cwvr.-t Pik- De: E City C -�r^c_ l
State ZZD 4 t,. o 3 Z Contac
Phone (3%-1) $y$ --7 L n S Cell phone
Emai N►kt.� Q Cc.r.•,e ��tc. ��k�..c
Paymen (circle on Web site address:
Check Credit Card pxt r" C—M
Amount enclosed (amount due: $99)
(Circle one): visa Mastercard Discover
American Express
Card number.
Exoiration:
Name on card
Indemnification: By its signature below, the above Club "Indemnitor" agrees to indemnify and
hold the NIHCA and participating HMO's "Indemnitees harmless with respect to any claims or
actions instituted by third parties that result from the use of Indemnitor's services or facilities,
including any claims for death, personal injury or property damage, deceptive trade practices,
or the use or misuse of information provided by Indemnitees.
Signature of Above Named Club C
Date 3
Fax back to 651.554.9935
400 10 St. NW, New Brighton, MN 55112 Ph. 866.484.9173 or 651.554.9416
Fitness Center Participation Agreement Page 13
Carmel Clay
Parks &Recreation CHECK REQUEST
Date: S U� ECEIVED
FEB 0 8 2008
Check payable to
1 I C
Name: lei �1
�U� �y S� M
Address: l_
City, State, Zip
Mail check to payee XReturn check to requestor
ay
Check Amount Date Required 74
Check needed for a-/')' /J Cr-
Supporting documentation or receipt(s) MUST be attached.
To be paid from
Po# /b�1, `-f.
Budget account GL �7 3UG CDC �t 3S S3�sf�
Budget Line Description
Requested by (print):
Requested by (signature):
Approved by (signature f Division Manager):
on this date
Form revised 1 -21 -08
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
Independent Health Club Assoc. (NIHCA) Terms
400 10th St. NW
New Brighton, MN 55112
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
2/8/08 none activation form 99.00
Total 99.00
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
Voucher No. Warrant No.
Independent Health Club Assoc. (NIHCA) Allowed 20
400 10th St. NW
New Brighton, MN 55112
In Sum of
99.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1047 none 4355300 99.00 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
3 -Mar 2008
i
ignature
99.00 sistant Director
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund