165403 10/29/2008 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
t, ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $2,121.00
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 165403
CHECK DATE: 10129/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 10009 2,121.00 MEDICAL EXAM FEES
I
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
0 Indianapolis, IN 46204
c Carmel Police Department I CARMEPD
3 Civic Square Terms
Carmel IN 46032 Invoice Date 10/14/2008
m:' Invoice 00 -10009
Date Employee Description Amount Balance Due:
09/24/08 Molter Matthew S. Exec Wellness Offsite $61.00 $61.00
HIV 1 &2 $0.00 $0,00
Quantiferon Tb Gold $50.00 $50.00
10101108 Harris Sarah E. Exec 1 Wellness Offsite $61,00 161.0c
HIV 1 &2 $0.00 $0.00
Quantiferon Tb Gold $50.00 $50.0 0
Malloy, Katherine E. HIV 1 2 $0.00 $0.00
Exec 1 Wellness Offsite $61.00 61.00
Q uantiferon Tb Gold $50.00 S50.001
10/06/08 White Kari E. Exec 1 Wellness 61.00 $61.00
IV 1 &2
Quantiferon Tb Gold $50.00 $50.00
10/08/08 Buttice Jennifer R. 10 Cities $234.00 $234.00
OnMed Program $10.00 $10.00
Treadmill (PFE) $165.00 $165.OD
Flexibilitv Check $7.00 $7.00
Waist/Hi Ratio $0.00 $0.00
Kin on David M. 10 Cities $234.00 $234.00
Treadmill (PFE $165.00 $165.00
Flexibility Check $7.00 $7.001
Waist/Hi Ratio $0.00 $0,00
10/09108 Henry, David R. 10 Cities $234.00 $234.00
O nMed Proaram $10.00 1
Treadmill (PFE $165.00 $165.00
Flexibility Check $7.00 $7.00
Waist/Hi Ratio $0.00 $0.00
10/10/08 Scott Curtis D. 10 Cities $234.00 $234.00
OnMed Program 10.00 $10.0 0
Treadmill (PFE) $165.00 165.00
Body Fat Check Bod Pod $23.00 $23.0 0
Flexibility Check $7.00 1 S7.00
Waist/Hip Ratio $0.00 $0.00
Total'dhar es :u $2,121::00
Total Payments &`Balance,Due x$0:00 $2;121.00
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date.
Presc'lfued by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Public Safety medical Services Purchase Order No.
324 E. New York Street, Suite 300 Terms
Indianapolis, IN 46204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10114/03 10009 for physicals 2,121.00
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
P ublic Safety Medical Services IN SUM OF
324 E. New Yor, street, Suite 300
Indianapoils, IN 46204
2,121.00
ON ACCOUNT OF APPROPRIATION FOR
pe!4,r.e general f;1Ad
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1110 10009 407 -01 2 121.00 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
October 24 2008
Signature
As tant Chief of Police
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund