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Home My WebLink About173495 06/10/2009 CITY OF CARMEL, INDIANA VENDOR: 359860 Page 1 of 1 ,•,�j CIVIC SQUARE PELHAM SPECIALITY TRAINING INC O 699 E DILLMAN ROAD CHECK AMOUNT: $350.00 CARMEL, INDIANA 46032 BLOOMINGTON IN 47401 CHECK NUMBER: 173495 CHECK DATE: 6/10/2009 DEPARTME ACCOUNT PO NUMBER INVOIC NUMB A MOUNT DESCRIPTION 1120 4357004 350.00 EXTERNAL INSTRUCT FEE �J Z V �i EMER ENCYMCD I CU. TnCr I C%1& W ILOCRNESs Invoice 09- 100530 099 E Dillman Road Date 6/5/2009 Bloomington, IN 47401 (812) 824 -7975 Due Date 8/17/2009 brett<<iipelhamtraining.com www.pclhamtr•aining.com Bill To City of Carmel, Indiana One Civic Square Carmel IN 46032 Quantity Description Rate Amount 1 EMT Refresher Paramedic for Barbara M Wynn 350.00 350.00 Indiana State Sales Tax (If Applicable) 7.00% 0.00 Pay your bills online at: https://www.intuitbillpay.com/pelhamspecialtytraininginc QuickBooks Users: Use the link below to review this invoice and download it as a bill into QuickBooks! https: workplace. intuit. com/ db/ bd7gd39a7 /gl/lnvoice2BiI1.htmI ?in voiceld= 7b6ffb8b -3b66- 4321- bIfd- 3eedf4d8745c 6638279016021 212173 Total $350.00 Payments /Credits $0.00 Balance Due $350.00 PELHAmTRAiNiNG EMERGENCY MEDICAL, TACTICAL WILDERNESS Course Registration Form Please fill out the course registration form completely and return to us by one of the following methods: Drop Off Mail: 699 E. Dillman Road, Bloomington, IN 47401 Fax: (812-) 824-7841 Scan and Email: info @pelhamtraining.com Student Information: Drivers License Number: UO 2 q Social Security Number: 3 0(o _CRS va First Name: J b 0- C-0,.. MI: Last Name: LJt3 Home Address: l a �0. City: S F4 ew- County: L 46;,q State /Province: ZIP /Postal Code: g603 -7 Country: A Shipping Address for Book if Different from Above: Daytime Phone Number: '7 5 Evening Number: Email Address (please Print Clearly): CL Vh Oe of rl ri C Date of Birth(mm /dd /yy): 0 q 4 7 Gender: Country of Citizenship: IC34 State /Country you will seek certification: :T A f Do you have any learning disabilities or handicap we need to be made aware of? fw No If yes, please describe: How did you hear about us? 1 5 _t_c :E M 15 Emergency Contact Information: Name: W Q. j K n n Relationship: 1- 0 Address: 9 3 U 3 s 4 �^,q C,4 Phone: Student License Information: Complete the following section for each license held. If no license is currently held lease skip over this section. State of current licensure: A-N/j Level of license: License number: License Expiration date: 7 NREMT#(if applicable): N IA- Next NREMT re- registration date (if applicable): /-OS T l L L g� Cancellation Policy: Payment is due at the time of your registration. Students who need to cancel and do so in advance will be entitled to a refund of a percentage of the cost of the course(s) as determined by the following schedule based on calendar days prior to the course start date. Date of cancellation will be determined by US Mail postmark or Email/Voice Mail DatefTime stamp. 100 28+ days 25 13 -7 days 75 27 -21 days 0 6 days or less including No -Shows 50 20 -14 days Page 1 of 3 PE LHAmTRAiNiNc, EMERGENCY MEDICAL, TACTICAL WILDERNESS Course Information: Please indicate which course you would like to take and the start date. Books are provided for specific courses which are indicated with an asterisk Course: Start Date X Recertification X Certification BLS Healthcare Provider Course CPR $25.00 35.00 EMT Courses: First Responder* $250.00 EMT Basic* $675.00 EMT Basic Accelerated* $1,200.00 Paramedic* $4,000.00 Anatomy $500.00 Paramedic Accelerated You must fill out the Paramedic Application Packet before you can register for this course. EMS Continuing Education Courses: EMT Basic Refresher $150.00 Par edic Refresher 6 $350.00 Continuing Education Unit Weekend CEU :00 Practical Exams and Prep Courses: BLS Practical Exam $100.00 ALS Practical Exam $125.00 National Registry Preparation Course NRPC $300.00 Wilderness Courses: Wilderness First Aid (SOLO)* $200.00 Wilderness Medical Upgrade* $375.00 Specialty Courses: PHTLS (Pre-Hospital Trauma Life Support) $75.00 $150.00 PALS Pediatric Advanced Life Support) $75.00 $150.00 PEPP BLS (Pediatric Edu. For Prehospital $50.00 $75.00 Professionals PEPP ALS (Pediatric Edu. For Prehospital $75.00 $100.00 Professionals AMLS Advanced Medical Life Support) $75.00 $150.00 ACLS Advanced Cardiac Life Support)* $75.00 $150.00 Subtotals: Course Total Recertification Subtotal+ Certification Subtotal ci6 I agree to comply with the policies and procedures of Pelham Training. I understand that if I knowingly provide false information, m Iment may be revoked, and may be cause for dismissal from the program. Signature: Date: Page 2 of 3 PELHAmTRAiNiNG EMERGENCY MEDICAL, TACTICAL WILDERNESS Method of Payment: (Payment due with registration form) The following forms of payment are accepted: Credit card Check or Money order Company /Other Credit Card: Check One: Visa MasterCard Discover Exp. Date (mm /yy) Card Number: Card Holder Name: Card Holder Billing Address: Card Holders Signature: *Any credit card information will be destroyed after a successful credit card transaction* Check or Money Order: Please make checks /money orders payable to Pelham Training. Pelham Training will assess a $30.00 fee for all returned checks. Your registration form will be held until your check or money order is received. Company /Other: If a company, government entity or educational institution is paying for your course(s) please complete the following section. Business Name: 1 Contact Name: Q �4 L /2E' Email Address: Address: C.y /7 uP� (24AIn n o z C/ V/ G �6`tC G1�2 City: State /Province: ZIP /Postal Code: Country: J Phone Number: Fax Number: '7� Z6zz &i =r7 Z6 Page 3 of 3 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)) $350.00 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. WARfZ�-NT N ALLOWED 20 Pelham Training IN SUM OF 699 E. Dillman Road Bloomington, IN 47401 $350.00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1120 43- 570.04 $350.00 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 jUN Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund