HomeMy WebLinkAbout165819 11/12/2008 CITY OF CARMEL, INDIANA VENDOR: T362164 Page 1 of 1
ONE CIVIC SQUARE INDIANA STATE CHEMIST- PURDUE
CARMEL, INDIANA 46032 175 SOUTH UNIVERSITY STREET CHECK AMOUNT: $45.00
WEST LAFAYETTE IN 46907 -2063
CHECK NUMBER: 165819
CHECK DATE: 11/12/2008
DEP ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1150 4355300 N35567 45.00 ORGANIZATION MEMBER
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2009 INDIANA PESTICIDE COMMERCIAL APPLICATOR RENEWAL APPLICATION
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BROOKSHIRE GOLF CLUB 't3o
12120 BROOKSHIRE PARKWAY
CARMEL IN 46033 -1212
Current Phone: (317) 846 -7431 Ext.
Current Fax: Q
Business e-mail:
Submit the Renewal Application and payment in the enclosed envelope before December 31, 2008.
Those applications postmarked after December 31, by law, require an additional 100% late fee
penalty (multiply total renewal fee by 2).
Certification in each category is valid for a five (5) year period.
A license and technician registration is renewed each year prior to Dece
License Number N35567
FEE $45.00 RENEW DO NOT RENEW
Personal e-mail:
ROBERT DAVID HIGGINS
CAT 313 9 CCHs earned out of 20 required Category Expires 12/3112012
otaI Fee Due: $45.00
Submit the Renewal Application and payment in the enclosed envelope before December 31, 2008.
Those applications postmarked after December 31, by law, require an additional 100% late fee
penalty (multiply total renewal fee by 2).
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))
Printed Name Job title of person signing
)l-
Signature Date
FOR STATE CHEMIST OFFICE USE ONLY
APPROVED DATE
Check No Amount Entered Under
GN 30022
Posted Account
PAL
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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
1,i4 "e?"/c" �e Q— ,7 /-s Purchase Order No.
Terms
Date Due
Invoice !tee Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
1
IN SUM OF
Mfrs �T�. �79D7 -3
ON ACCOUNT OF APPROPRIATION FOR
Board Members
I NO. ACCT #/TITLE AMOUNT
DEPT I hereby certify that the attached invoice(s), or
/U9S S6 7 1 1 351 3 S 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
20
Signature
I�irprtnr of C'nlf
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund