HomeMy WebLinkAbout169014 02/17/2009 CITY OF CARMEL, INDIANA VENDOR: 00351400 Page 1 of 1
ONE CIVIC SQUARE INDIANA FIRE CHIEFS ASSN.
CARMEL, INDIANA 46032 P o BOX 364 CHECK AMOUNT: $475.00
ZiONSViLLE IN 46077 CHECK NUMBER: 169014
CHECK DATE: 2/17/2009
DEPART ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4355300 475.00 ORGANIZATION MEMBER
I
INDIANA FIRE CHIEFS ASSOCIATION
a F' 2009 MEMBERSHIP APPLICATION
Name: Keith Smith
Title: Fire Chief Department Name: Carmel Fire Department
Department Address: 2 Civic Square
City: Carmel State: IN ZIP Code: 46032
Phone: 317 571 -2600 E -Mail: Ksmith@carmel.in.gov Fax: 317 -571 -2615
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
MEMBERSNIP,CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I. F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES (CHECK- JOINANYORALL)
EMS 25.00 Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE. AND PAYMENT METHODS
Active Chief Assistant/Deputy Chief (30 or more in Dept.) 75.00 each
Active Other Chief Rank (30 or more in Dept.) 50.00 each Member Dues
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names Section Dues
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active (by approval) Free TOTAL DUES: nS
If an invoice is needed please complete application and indicate here with your initials
Check (payable to mca) Visa MasterCard
Card Number: Expiration Date:
Name On Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317 -733 -4212 Toll Free: 1- 877 733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship Opportunities Available Please see otir website'at www.indfrechiefs.org or
contact Terry Rake, IFCA Executive Director at 3171 733 -1850 or 'rake @indfirechiefs,org.
INDIANA FIRE CHIEFS ASSOCIATION
a Y 2009 MEMBERSHIP APPLICATION %�a n
Name: Mark Hulett
Title: EMS Chief Department Name: Carmel Fire Department
Department Address: 2 Civic Square
City: Carmel State: IN ZIP Code: 46032
Phone: 317 571 -2600 E -Mail: mhulett @carmel.in.gov Fax: 317- 571 -2615
1
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
MEMBERSHIP CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
D epartmental Membership.
DEPARTMENTAL MEMBERSHIP— Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification f rom the B oard of Directors.
MEMBER SECTIONS DUES (CHECX —JOIN ANY OR ALL)
EMS 25.00 Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE AND PAYMENT METHODS
Active Chief Assistant/Deputy Chief (30 or more in Dept.) 75.00 each
f( Active Other Chief Rank (30 or more in Dept.) 50.00 each Member Dues �Q
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names Section Dues a
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active (by approval) Free TOTAL DUES: h�
If an invoice is needed please complete application and indicate here with your initials
Check (payable to rFrA) Visa MasterCard
Card Number: Expiration Date:
N a m e O Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317- 733 -4212 Toll Free: 1- 877 733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship 'Opportunities Available Please'see our website at www.indfirechiefs.org or
contact Terry Rake, ,IFCA 'Executive Director at 317 -733 -1850 or rake @indfirechiefs.org.
.......y INDIANA FIRE CHIEFS ASSOCIATION
G 2003 MEMBERSHIP APPLICATION
Name: David Haboush
Title: Assistant Chief Department Name: Carmel Fire Department
Department Address: 2 Civic Square
City: Carmel State: IN ZIP Code: 46032
Phone: 317 -571 -2600 E -Mail: dhaboush @carmel.in.gov Fax: 317 -571 -2615
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
MEMBERSHIP CATEGORIES.,
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileg
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES (04CK- Jorro.nrvrortaL4)
EMS 25.00 Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE AND PAYMENT METHODS
Active Chief Assistant/Deputy Chief (30 or more in Dept.) 75.00 each
V Active Other Chief Rank (30 or more in Dept.) 50.00 each Member Dues S
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names Section Dues
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active {by approval} Free
TOTAL DUES: SQ
If an invoice is needed please complete application and indicate here with your initials
Check (payable to iFca) Visa MasterCard
Card Number: Expiration Date:
Name O Ca
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317 733 -4212 Toll Free: 1- 877- 733 -1850
Online: www.indfirechiefs.o E M a il: ra
Sponsorship Opportunities Available Please see our website at www.indfirechiefs.org or,
contact Terry Rake, IFCA Executive, Director at 317 -733 -1850 or rake @indfirechiefs.org.
INDIANA FIRE CHIEFS A r.
a 2009 MEMBERSHIP APPLICATION
Name: Jeff Steele
Title: Assistant Chief Department Name: Carmel Fire Department
Department Address: 2 Civic Square
City: Carmel State: IN ZIP Code: 46032
Phone: 317 571 -2600 E -Mail: jsteele @carmel.in.gov Fax: 317 571 -2615
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
i MEMBERSHIP CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES (cM cK- JXNaNroa, LL)
EMS 25.00 Public Safety Educator 25.00
Technical Rescue 25.00
MEM BER DUES STRUCTURE AND PAYMENT METHODS
Active Chief Assistant /Deputy Chief (30 or more in Dept.) 75.00 each
Active Other Chief Rank (30 or more in Dept.) 50.00 each Member Dues Sd
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names Section Dues
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active (by approval) Free
TOTAL DUES: S Q
If an invoice is needed please complete application and indicate here with your initials
Check (paraare Visa MasterCard
Card Number: Expiration Date:
Name On Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317 733 -4212 Toll Free: 1- 877 733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship Opportunities Available Please see our'website at vuww.indfirechiefs.org or
contact Terry, Rake; IFCA Executive Director at 317- 733- 1850,o:r rake @indfirechiefs.org.
°•..4 INDIANA FIRE CHIEFS ASSOCIATION
bo o ry f 2009 MEMBERSHIP APPLICATION
Name: Matt Hoffman
Title: Training Chief Department Name: Carmel Fire Department
Department Address: 2 Civic Square
City: Carmel State: IN ZIP Code: 46032
Phone: 317 571 -2600 E -Mail: mhoffman @carmel.in.gov Fax: 317- 571 -2615
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
MEMBERSHIP CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
hol ding elected office and voting pr ivileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES (CHECK JOINANYOR ALL)
EMS 25.00 Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE AND PAYMENT METHODS
11 Active Chief A5sista n t/ Deputy Chief (30 or more in Dept.) 75.00 each
[a Active Other Chief Rank (30 or more in Dept.) 50.00 each Member Dues S
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names Section Dues a�
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active (by approval) Free
TOTAL DUES: n5
If an invoice is needed please complete application and indicate here with your initials
Check (payable to7Fc4) Visa MasterCard
Card Number: Expiration Date:
Name On Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317 733 -4212 Toll Free: 1 -877- 733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship Opportunities Available —Please see our website at www.indfirechiefs.org or
contact Terry Rake, IFCA Executive Director at 317 733 =1850 or rake @indfirechiefs.org,
INDIANA FIRE CHIEFS ASSOCIATION
2009 MEMBERSHIP APPLICATION
Name: Keith Freer
Title: Public Education Director Department Name: Carmel Fire Dept.
Department Address: 2 Civic Square
City: Carmel State:IN ZIP Code: 46032
Phone: 317- 571 -2600 E -Mail: kfreer @carmel.in.gov Fax: 317 571 -2674
State Senate District: US Congressional Distrct: IN Homeland Security District:
State Representative District:
MEMBERSHIP CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES {CHECK- 70INANYORALO
EMS 25.00 _X— Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE AND PAYMENT METHODS
Active Chief Assistant/Deputy Chief (30 or more in Dept.) 75.00 each
Active Other Chief Rank (30 or more in Dept.) 50.00 each �0
Member Dues
Departmental Combo/Vol Dept. less than 30 $100.00 �1
(please provide Dept. Roster) attach roster list of members names Section Dues
11 Associate Non Chief Rank (more than 30) or Interested Individuals 50.00 �7
TOTAL DUES:
Retired Active (by approval) Free
If an invoice is needed please complete application and indicate here with your initials
Check (payame to zFca) Visa MasterCard
Card Number: Expiration Date:
Name On Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.O. Box 364, Zionsville, IN 46077
By Fax: 317- 733 -4212 Toll Free: 1- 877 -733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship Opportunities Available Please see our website at www.indfirechiefs.org or
contact Terry Rake, IFCA Executive Director at 317- 733 -1850 or rake @indfirechiefs.org.
INDIANA FIRE CHIEFS ASSOCIATION
2009 MEMBERSHIP APPLICATION oa^r
Name: Bruce Knott
Title: Fire Marshal Department Name: Carmel Fire Dept.
Department Address: 2 Civic Square
City: Carmel State:IN ZIP Code: 46032
E Phone: 317- 571 -2600 E -Mail: bknott@carmel.in.gov Fax: 317- 571 -2674
State Senate District: US Congressional District: IN Homeland Security District:
State Representative District:
MEMBERSHIP CATEGORIES
ACTIVE MEMBERSHIP Active Membership shall be comprised of the Chief of Department and any Chief Officer Rank of a
regularly organized Fire Department officially recognized by the State Fire Marshal's Office. Active members shall be entitled to
vote on all matters requiring a vote unless otherwise prohibited by the Constitution and By -Laws and shall be entitled to hold
elective office. For departments with less than 30 emergency responders, the Fire Chief and one (1) Assistant Deputy Chief will
be identified as active members who will have voting rights, all others of that department will be considered to have
Departmental Membership.
DEPARTMENTAL MEMBERSHIP Departmental Membership shall be comprised of each additional member beyond the Fire
Chief and one (1) Assistant Deputy Chief of a department with less than 30 emergency responders. Departmental Members
shall be entitled to participate fully in the affairs of the Association, with the exceptions of holding elective office and voting
privileges. attach roster list of member names.
ASSOCIATE MEMBERSHIP Associate Membership shall include individuals interested in the protection of life and property
from fire. This also includes all members of a department with 30 or more emergency responders who are not the Fire Chief or a
Chief Officer. Associate Members shall be entitled to participate fully in the affairs of the Association, with the exception of
holding elected office and voting privileges.
RETIRED ACTIVE MEMBERSHIP Retired Active Membership shall include only Active Members who have retired from the
Fire Service after ten (10) consecutive years, as members of the I.F.C.A. Retired Active Members shall be entitled to participate
fully in the affairs of the Association, with exception of holding elective office. Retired Active Membership may be obtained by
application to and certification from the Board of Directors.
MEMBER SECTIONS DUES (CHECK- JOr NANroRAll)
EMS 25.00 X— Public Safety Educator 25.00
Technical Rescue 25.00
MEMBER DUES STRUCTURE AND PAYMENT METHODS
Active Chief Assistant/Deputy Chief (30 or more in Dept.) 75.00 each
Active Other Chief Rank (30 or more in Dept.) 50.00 each
Member Dues
Departmental Combo /Vol Dept. less than 30 $100.00
(please provide Dept. Roster) attach roster list of members names S
Section Dues
Associate Non Chief Rank (more than 30) or Interested Individuals 50.00
Retired Active (by approval) Free
TOTAL DUES:
If an invoice is needed please complete application and indicate here with your initials
Check (payable m r c4) Visa MasterCard
Card Number: Expiration Date:
Name On Card:
Signature:
Easy Ways To Join. Return application and payment:
By Mail: IFCA Membership Application, P.Q. Box 364, Zionsville, IN 46077
By Fax: 317 733 -4212 Toll Free: 1- 877 -733 -1850
Online: www.indfirechiefs.org E -Mail: rake @indfirechiefs.org
Sponsorship Opportunities Available Please see our website at www.indfirechiefs.org or
contact Terry Rake, IFCA Executive Director at 317- 733 -1850 or rake @indfirechiefs.org.
VOU CHER NO. WARRANT NO.
ALLOWED 20
I FCA
Indiana Fire Chiefs Association
IN SUM OF
P.O. Box 364
Zionsville, IN 46077
$475.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1120 43- 553.00 $475.00 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
FEB 13 2009
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))
Dues Smith, Steele, Haboush, Hulett, Hoffman, Knott, Freer $475.00
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