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Home My WebLink About170913 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 353810 Page 1 of 1 is ONE CIVIC SQUARE INDIANA PARK RECREATION /r CARMEL, INDIANA 46032 269 WEST JACKSON STREET CHECK AMOUNT: $90.00 PO BOX 888 CHECK NUMBER: 170913 ON CICEROIN 46034 CHECK DATE: 4/16/2009 DEPARTMENT ACCOUNT PO NUMBER I NVOICE NUMBER AMOUNT DESCRIPTION 1047 4358300 S CARLING 50..00 OTHER FEES LICENSES 1047 4358300 T PINTER 40.:,00 OTHER FEES LICENSES Carmel C lay Parks &Recreation CHECK REQUEST 1 3 9139VT9 Date: A APR 0 7 2009 ]BY: 1 4 Check payable to Name: j C r lL�n �.�.I on Address: U y &-L L S I d ex_- PC 9 City, State, Zip 1 �4 H LQ D S Mail check to payee 1/ Return check to requestor a Check Amount o Date Required X11 &Q 1 I q Check needed for: 0L&!--6,fa "f l y -6 n To be paid from PO (if applicable) Budget account GL 00 00 Budget Line Description 4 b Q n Invoice(s) and Purchase Order (if required) MUST be attached: Requested by (print): t N Requested by (signature): d z-L� Approved by (signature of Division Manager): on this date Form revised 7 -7 -08 Shared Administrative Forms I Staff forms Check Request (rev 7 -7 -08) fit" d MAT�CPJAi, Indiana Park and Recreation Association Certification Board Certification Application Form Q APR 072009 BY Please Prin! or Type Title (e.g. hir. &lrs Fi rst Name: Middle Initial: LastName: �t� Suffix: Name (:as you wish it to appear on your certificate); Pc Oe —c Home Address: I J' 1 111 OOO W I S LQ City; �1� E� -f z State: Zip: Home Phanc: Business Phone: d` J Email Address; A io c f e C0 il'IP.I C ln..1()a oy r1 Are you a military or federal government employee? YES NO Are you an NRPA member`? YES NO If yes, membership LSvel of Certification Reauested Please review eligibility criteria on pages 5 6 Please circle one category: NRPA Member Non member Professional C x=10 D $50.00 Provisional $35.00 $45.00 Associate $30,00 $40.00 If the Certification Review Board finds that you should be certified at a level diffe nt from the one you requested, will you accept the level deemed appropriate by the board? Ye No Form of Payment; V check credit card Account 4: Expires: Signature: FOR OFFICE USE ONLY: Testing Expiration Date: Application approved? Exam Application sent: Certification Renewal date: Exam Application received: Eligible to Test: Database: Indiana Park Recreation Assodabon, P.O. Box 888, Cicero, Indiana 46034 ACADEMIC PREPARATION Please submit one official transcript verifying the educational requirements of the certification level you are seeking. Please review education requirements for your desired certification level on pages 5 6. Unofficial transcripts and faxed copies will not be accepted. If your transcripts are sent separately, a. type- written note to that effect must accompany this application. NRPA cannot be responsible for requesting transcripts on behalf of applicants or for initiating a confirmation of receipt of transcripts. College/University College/University State Dates Attended 1 Major/Degree Degree Date vtGu'\a 11u.V� Ylly� oyu A notarized affidavit of academic work may be submitted for special consideration in cases where the school or college no longer exists, or in the case where records have been destroyed by fire or other disasters. `YORK EXPERIENCE If necessary for the certification level for which you are applying, please list your PAID, FULL TIME, YEAR ROUND experience in parks, recreation, or leisure services. Volunteer, part -time, and seasonal work are not acceptable. Starting with your current position, list, in order, as many positions as necessary to satisfy the experience requirements for your level of certification. For each position you list, there must be a letter attached to this application from a Human Resources/Personnel official OR supervisor verifying the related work information contained in your application is accurate and complete. This letter must be submitted on company letterhead and signed. The letter should include, at a minimum, Agency Name, Agency Address, Agency Phone Number, your Job Title, and Dates of Employment. Agency l U.1 }S l� (D�V �7Q.1 fC "talk �1�1'l Job Title 1 �tl t D 11 A2encv Address City Om 10C I f State Zip Code Name Title of Supervisor �C \ylEld.c ��1S1 Ol L\AfmA&al_.f Phone SaaL Dates ofEmgl4vment (MiY) to �'C ��t,-�1 CC (1 Job Duties: Indiana Park Recreation ,Association, P.O- Box 888, Cicero. Indiana 46034 WORK EXPERIENCE Continued Asencv l �f•rn�,l N&O Pa.� l P�e'(`�7nn Job Title �ne(a,t< <'rtrn �Pxu AQencv Address I �J� l I I Part- hx_ &S� Ci y �3a City (�..r��. State I Zip Code Name Title of Supervisor {�LA hn� ieCi�,r 12 L' m Phone Dates of Employment (M[ /Yl I to Job Duties: A2encv Job Title Agency Address City State Zip Code Name Title of Supervisor Phone Dates of Emplovment 04Y) to Job Duties: Total number of years of paid, full -time, year round experience in park, recreation, or leisure services: -3- Indiana Park Recreation Association, P.O. Box 888, Cicero, Indiana 46034 NOTARIZATION OF APPLICATION AGREEMENT TO ALL TERMS By signing, I certify that all the information given in this application is true and correct to the best of my knowledge. I further understand that false representation relative to any information will provide the basis for withdrawal of certification. Your signature must be in the presence of a notary public.. sworn to under oath and penalty of perjury, and must be affixed with an official notary seal. Applications without notary signature will not be accepted. PRINTED NAN E:: �S j P In IC SIGNATLIRE: +J DATE: Notary Public of the State of County of On this day of 20 the applicant personally appeared before me and stated under oath and penalty of perjury that the information contained in this application is true and correct. Notary Signature SEAL,: My Commission Expires: Did you remember to enclose: Completer) signed notarized form Payment Academic Transcripts Verification of work experience Certification Application Please return application, payment and documentation of academic and work credentials to: IPRA Park and Recreation Association Certification Board P. O. Box 888 Cicero, Indiana, 46034 A Indiana Park Recreation Association, P.O. Box 888, Cicero, Indiana 46034 .N A 0 `4 .c. Indiana Park and Recreation Association Certification Board Certification Application Form Please Print or Type Titie (e.a. Mr. Alm.): f�I�S. First Name: Middle Initial: Last Name: r n!1 Suffix: C7 Name (as you wish it to appear on your certificate); )a ATJ, I j/1 0( Home Address: City: l r ]Q� t� State: zip: Z yv Home Phonc: 3I 2 T T-3 J 13 Business Phone: 3 7 0 3 5 z v3 Email Address; 1 r nC Cj C'--� 3'✓I Are you a military or federal government employee? Y I NO Are you an NRPA member? YES NO If yes, membership L o f Certification Reg tiested Please review eligibility criteria on pages 5 6. Please circle one category: NRP e er Non member f ssional 0.00 Provisional $35.00 $35.00 Associate 530,00 $40.00 If the Certification Review Board finds that you should be certified at a level different from the one you requested, will you accept the level deemed appropriate by the board? Yes No Form of Payment: check credit card Account 7: Expires: Signature: FOR OFFICE USE ONLY: Testing Expiration Date: Application approved? Exam Application sent: Certification Renewal date: Exam Application received: Eligible to Test: Database: Indiana Park Recreation Assodation. P.O. Box 888, Cicero. Indiana 46034 ACADEMIC PREPARATION Please submit one o)' transcript verifying the educational requirements of the certification level you are seekine. Please review education requirements for your desired certification level on pages 5 6. Unofficial transcripts and faxed copies will not be accepted. If your transcripts are sent separately, a type written note to that effect must accompany this application. NRPA cannot be responsible for requesting transcripts on behalf of applicants or for initiating a confirmation of receipt of transcripts. CoBe e /University State Dates Attended Major /Degree Degree Date A notarized affidavit of academic work may be submitted for special consideration in cases where the school or college no longer exists, or in the case where records have been destroyed by fire or other disasters. WORK EXPERIENCE If necessary for the certification level for which you are applying, please list your PAID, FULL -TINW, YEAR -ROUND experience in parks, recreation, or leisure services. Volunteer, part -time, and seasonal work are not acceptable. Starting with your current position, list, in order, as many positions as necessary to satisfy the experience requirements for your level of certification. For each position you list, there must be a letter attached to this application from a Human Resources/Personnel official OR supervisor verifying the related work information, contained in your application is accurate and complete. This letter must be submitted on company letterhead and signed. The letter should include, at a minimum, Agency Name, Agency Address, Agency Phone Number, your Job Title, and Dates of Employment. a Atrenc ICS Job Title t? Aaencv Address 2 City 0 State Zia Code p i S' p 1� Name &Title of Su ervisor Q y� Phone `17 7 s r' 5 Dates of Employment (MfY) J/� to t v Job Duties: Indiana Park Recreation Assoaaton, P.O. Box 888, Cicero, Indiana 46034 WORK EXPERIENCE Continued AQencv Job Title AQencv Address City State Zip Code Name Title of Supervisor Phone Dares of Employment (ivVY) to Job Duties: AQencv Job Title AQencv Address City State Zip Code Name Title of Supervisor Phone Dates of Employment MWYI to Job Duties: Total number of years of paid, full -time, year round experience in park, recreation, or leisure services: -3- Indiana Park Recreation Association, P.O. Box 888, Cicero, Indiana 46034 NOTARIZATION OF APPLICATION AGREEMENT TO ALL TER_ML S By signing, t certify that all the information given in this application is true and correct to the best of my knowledge. 1 further understand that false representation relative to any information will provide the basis for withdrawal of certification. Your sisnature must be in the presence of a notary public, sworn to under oath and penalty of perjury, and must be affixed with an official notary seal. Applications without notary signature will not be accepted. PRINTED NAN1 a a �A l,{ SIGNATUR DATE: 27�>-- Notary Public of the State of Countvb On this day of 24 the applicant personally appeared before me and stated under oath and penalty of perjury that the information contained in this application is true and correct. Notary Signature SEAL: My Commission Expires: Did you remember to enclose: Completed signed notarized form Payment Academic Transcripts Verification of work experience Certification Application Please return application, payment and documentation of academic and work credentials to: IPRA Para: and Recreation Association Certification Board P. O. Box 888 Cicero, Indiana, 46034 -4- Indiana Park Recreation Association, P.Q. Box 888, Cicero, Indiana 46034 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of 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. 353810 Indiana Park Recreation Association Terms P.O. Box 888 Cicero, IN 46034 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) PO Amount 4/7/09 T.Pinter Certifaction Application 40.00 4/7/09 S. Carling Certifaction Application 50.00 Total 90.00 1 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. 353810 Indiana Park Recreation Association Allowed 20 P.O. Box 888 Cicero, IN 46034 In Sum of 90.00 ON ACCOUNT OF APPROPRIATION FOR 104 Program Fund PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members Dept 1047 T.Pinter 4358300 40.00 1 hereby certify that the attached invoice(s), or 1047 S. Carling 4358300 50.00 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 8 -Apr 2009 Signature 90.00 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund