HomeMy WebLinkAbout178833 10/28/2009 CITY OF CARMEL, INDIANA VENDOR: 363546 Page 1 of 1
ONE CIVIC SQUARE PURDUE UNIV -IN STATE CHEMIST
CARMEL, INDIANA 46032 175 SOUTH UNIVERSITY ST CHECK AMOUNT: $45.00
W LAFAYETTE IN 47907 -2063 CHECK NUMBER: 178833
CHECK DATE: 10/28/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AM DESCRIPTION
1207 4358300 45.00 OTHER FEES LICENSES
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Page 1
2010 INDIANA PESTICIDE COMMERCIAL APPLICATOR RENEWAL APPLICATION
BROOKSHIRE GOLF CLUB
12120 BROOKSHIRE PARKWAY
CARMEL IN 46033-12`12
Current Phone: (317) 846 -7431 Ext.
Current Fax: O
Business e-mail:
Submit the Renewal, Application and payment'in the enclosed envelope be fore December 31
Those applications postmarked after December 31, by law, require an additional 100% late fee penalty
Certification in each category is valid for a five (5) year period.
A license and technician registration is renewed each year prior to December
License Number N35567
FEE $45.00 RENEW DO NOT RENEW
ROBERT DAVID HIGGINS Personal e-mail:
Category 3B 20 CCHs earned out of 20 required Category Expires 12131/2012
otal Fee Due: $45.00
Submit the Renewal Application and payment in the enclosed envelope before December 31, 2009.
Those applications postmarked after December 31, by law, require an additional 100% late fee penalty
I 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))
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Printed Name Job title of person signing
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Signature f Date
FOR STATE CHEMIST OFFICE USE ONLY
APPROVED DATE
Check No Amount Entered Under
GN 30022
Posted Account#
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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
f il' 0:�P CJ/1r 1�7��T Purchase Order No.
AUWu.e u,J
/tI Sc>4 -fry u��fP�s Terms
L�r �r Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
A3 <CWA_1 �ell
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
IN SUM OF
cc..�2,i7cti.� L1N k J
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ON ACCOUNT OF APPROPRIATION FOR
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Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
-C6 ;646 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 0j
a
S ignature
l�n�CS
itle
Cost distribution ledger classification if
claim paid motor vehicle highway fund