205193 01/05/2012 CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1
f ONE CIVIC SQUARE HENRY SCHEIN INC
CARMEL, INDIANA 46032 DEPT CH 10241 CHECK AMOUNT: $1,273.20
PALATINE IL 60055 -0241 CHECK NUMBER: 205193
CHECK DATE: 1/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 4839822 -01 1,273.20 SPECIAL DEPT SUPPLIES
HSI ORDER ORDER DATE DUE DATE
96663603 12/16/11 01/15/12
WHSE DEA#0 RHO] 62494 Fed ID: 11-3136595
Ro
imgm ME 'a b�
li
his order has been processed by our MIDWEST D,C.
5315 WES 74TH 3TREET
INDIANAP LIS,IN 46268
MIDWEST D.C. State Lic 23 00304
1 555 -5396 PU EA PROTECTIV ACUVNC SFT OATH 20X1.25 100 100 2.73 273.00 9
2 101 -2323 12 /BX CLOTH SURGICAL TAPE 1 12 12 C 7.71 92.52 1
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY-
3 101 -5979 6 /BX CLOTH SURGICAL TAPE 2 8 8 7.71 61.68 9
4 107 -0530 100 /BX PURPLE NITRILE PF GLOVE LARGE 40 40 C 8.25 330.00 5
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
5 153 -2007 20 /RL BIOHAZARD BAG 14.5X19 RED 3GAL 10 10 C 2.00 20.00 6
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
6 602 -8100 EA COLLAR STIFNECK SELECT ADULT 50 50 C 5.50 275.00 7
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
7 338 -2276 PU 100 /CA EXTENSION SET STD BORE UL 1 1 C 221.00 221.00 8
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
F YOU ARE ARTICIPATING IN A DISCOUNT PROGRAY (E.G. POIN S, GIFTS OR OTHER
PECIAL AWA ZIDS "DISCOUNT WITH THIS PURCHASE YOU HAVE PARNED A CREDI TOWARD
GOODS OR S RVICES, RECEIVABLE OR REDEEMABLE N ACCO ZDANCE WITH DISCOUNT PROGRAM
RULES. UPO DISCOUNT RECEIPT OR REDEMPTION, OU ARE RECEI ING OR WILL R CEIVE
1311.1, TO SHIP INN cz# INVOICE AMOUNT ITEM STATUS KEY REM KEY
1308571 1817102 4839822 -01 1273.20 li-
u aeAurdcrcd:hemwdllounw sK- seb.ticil
H I RDER ORDER DATE INS I E DATE F BORE l] Di
,scominued: hum no longer availahle NC Nn Churgc
I'- Special 5chtio 1 (.3nnds
96 6Q 12 2 9 N1- Nlanuranurer will ship Ilan di—fly royou
P- Ih r9c ri plian Drug; Return Amhon,aa- Rcyuircd
R Rcl iigU atal 11cm; May he ahippcd separately
CUS TOMER P PA E Special khcin Pricing
ARK IJ "remporarily un.- lablo; please rcordcr
1 OF 2 r Taxable teem Continued on [Next Page
LP300
HENRY SCHEIN@
SHIP TO /SOLD TO:
EMS Carmel Fire Department MI
135 Duryea Road, Melville, NY 11747 ®I 540 W 136 St
Station 46 Michael Kaufmann
Carmel,IN 46032 -8806
010000130857104839822110010000001273201216119 BILL TO:
Carmel Fire Dept MI
2 Civic Sq
Carmel, IN 46032 -7543
Carmel Fire Dept MI
2 Civic SCI BILL TO SHIP TO INVOICE AMOIIN1
Carmel, IN 46032 -7543 1308571 1817102 1273.20
INVOICE# INVOICE DATE
4839822 -01 12/16/11
CUSTOMER PO
NIARK
I'Icase detach here and mail the ahove with your payment
HSI ORDER# ORDER DATE DUE DATE
96663603 12/16/11 01/15/12
WHSE DEA# RH0162494 Fed Ill: 11-3136595
0
OTICE OF TIE DISCOUNT VALUE. FROM TIME TO TIME, MEDICARE, MEDICAID, TR2 ARE OR
THER PAYER MAY REQUEST INFORMATION REGARDING SUCH V LUE, PND UPON ANY 5 CH
REQUEST, SU H VALUE MUST BE DISCLOSED AS A DI COUNT GAINSI THE PURCHASE THAT
EARNED SUCH VALUE. ACCORDINGLY, YOU SHOULD RE AIN THESE RECORDS.
MERCHANDI E TOTAL 1273.20
nvoice Date 30 days 1273.20
LEASE NOTE NEW REMIT TO ADDRESS
lease remi payments only to the following a dress:
ENRY SCHET4 INC.
EPT CH 10211
ALATINE, I 60055 -0241
BILL TO SHIP TO INVOICE AMOUNT ITEM STATUS KEY REM KEY
1308571 1817102 4839822 -01 1273.20 li- B'Aordured: I(cm will loll— Ste Schooltci
H I ORDER4 ORDER DATE INVOICE DATE F 60XE I) DJsarntioucd; Jiem no lonecr available ,C- No Charge
1- Special Schein hrec Clouds
N1 Manufacturer will ship Item directly to you
96663603 12 16 11 12/16/11 9 J'- Prescription Drug: Rcmm Authorization Required
CUS TOMER P PA E 12 Refrigerated Item: May he shipped scpardiely
Special Schein Pricing
MARK 2 OF 2 T -T- nMe l lour unirvailablc; please reorder
LP300
H ENRY SCHEIN"
TERMS OF' S ALE
EMS
P yr e t Terwisw
We "rake every effort to maintain prices for the duration of a Payment by CHECK or by the HENRY SC EIN CREDIT CARET,
catalog, however, we reserve the right to make price adjustments in VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS
response to manufact3rers' price changes
Guaranteed Satisfaction: A`
If you have tried a product and it is defective or does not perform B ill Your O r d er Yo ur Op Account
satisfactorily, we will provide a credit, refund, or exchange; it's your Available to licensed practitioners in the U.S. All invoices are
choice. Simply call our customer service department within 30 days payable within 30 days,
of receipt of the merchandise to arrange for the return. For a
Warranty repair or if you were sent something you did not order,
simply call: Rx Products Controlled Substances:
I atrx Medical 1 ®800 845.3550
Regulations require us to limit the sale of px and controlled
substances only to registered, licensed healthcare professionals.
If you are a new customer or have recently moved, please furnish
us v, a copy of your updated state registration, For controlled
substances, furnish a copy of your DEA certificate. verifying your
shipping address. Class II drugs can be ordered only by mail.
International Orders:
Please Not
Opened handpieces and equipment may not be returned for We proudly serve hleaithcare pro;ess o+1ais arici governfnerrf
credit, but 4 ^.ill be repaired or replaced in accordance with throughout the world. To place orders or for inquiries on export
terms and cor5ditions, please contact our lnternationa! Department:
manufacturer warranties. Before opening han:fpieces or 1 800 845 35
equipment, we suggest that you check the shipping container 0
and packing list to verify that you have received exactly what Prescription Drug returns Instructions
you ordered,Opened Computer Software is not returnable.
Other restrictions may also apply.
A Return Authorization is Required for all Prescription DRigs. Simply call
our Customer Service Department ;�Z 110 -845 -3550.
a g
w Y
VOUCHER NO. WARRANT NO.
ALLOWED 20
Henry Schein
IN SUM OF
Dept Ch 10241
Palatine, IL 60055
$1,273.20
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# 1 Dept. INVOICE NO, I ACCT /TITLE I AMOUNT Board Members
1120 f 4839822 -01 1 102- 390.11 I $1,273.20 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
L
s
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4839822 -01 $1,273.20
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