200826 08/30/2011 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH gER1L
CARMEL, INDIANA 46032 P O BOX 19383 C13ECK AMOUNT: $315.40
INDIANAPOLIS IN 46219 CHECK NUMBER: 240826
CHECK DATE: 8/3012011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 297451 225.00 MEDICAL FEES
1082 4340700 297451 45.00 MEDICAL FEES
1091 4340700 297451 45.00 MEDICAL FEES
Community Occupational Health Services ((,1
P.O. Box 19383 Purchase r
Indianapolis, IN 46219 Description `r _T_
Phone: 317 -355 -6335 P.O. P or F
FEIN: 35- 1955223
9 fl escr� e- �D T!�� aser Date g l 1 AI `G o 8 2011 Date
AUG �/S �0
August 04, 2011 L 4 `r'D700
a t09l- 4 g3Y67M I AAYa
Bill to: Lynn Russell For: Crta a Cla Y Parks 9 R ys' as
Cannel Clay Parks Recreation 7/11
1411 E. 116th St.
Carmel, IN 46032
mn_. _m-_.-
Invoice 297451
Proc Code ICD9 Date Description Qty Charge Receipt Adjust Balance
31647 1) 844.9 07/18/2011 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
2) 782.3
Sarah E Alley Balance Due: 45.00
31647 07/12/2011 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Samantha R Czarnik Balance Due: 4
31647 07/27/2011 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Colleen L Fouse Balance Due: 45.00
31647 07/01/2011 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Jennifer L Gerber Balance Due: 4 5.00
31647 07/20/2011 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Michael W Kremer Balance Due: 1
31647 07/20/201 1 Drug Screen Non NIDA 5 Panel 1.00 45.00 b 45.00
Emily G Kyle Balance Due: 4 5.00
31647 07/12/2011 Drug Screen Non N I DA 5 Panel 1.00 45.00 45.00
Mitchell J Moore Balance Due: 45.00
31647 07/28/201 I Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Anna J Weifenbach Balance Due: 45
Invoice 297451 Balance .Due: 3 00
PLEASE REMIT PAYMENT PROMPTLY O)Y 0
Cut and retuni with payment
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.
355031 Community Occupational Health Services Terms
P.O. Box 19383
Indianapolis, IN 46219
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
814111 297451 Pre -em to meat drug testin 45.00
814111 297451 Pre-employment dru testing 225.00
814111 297451 Pre -em to ment drug testin
45.00
Total 315.00
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,
355031 Community Occupational Health Services Allowed 20
P.O. Box 19383
Indianapolis, IN 46219
In Sum of
315.00
ON ACCOUNT OF APPROPRIATION FOR
108 ESE 1109 Monon Center
PO# or INVOICE NO. ACCT #1TITILE AMOUNT Board Members
Dept
1091 297451 4340700 45.00 1 hereby certify that the attached invoice(s), or
1081 -99 297451 4340700 225.00 bill(s) is (are) true and correct and that the
1082 -99 297451 4340700 45.00 materials or services itemized thereon for
which charge is made were ordered and
received except
23 -Aug 2011
Signature
315.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund