180036 12/08/2009 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH g
CARMEL, INDIANA 46032 P 0 BOX 19383 MK AMOUNT: $148.00
INDIANAPOLIS IN 46219 CHECK NUMBER: 180036
CHECK DATE: 12/8/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 251677 148.00 CONT SVS- OTHER -S PLAN
.4
Community Occupational Health Services
P.O. Box 19383
Indianapolis, IN 46219
317- 355 -6335
Tax ID 35- 1955223
Invoice
November 04, 2009
s
Bill to: Shelly Lingelbaugh For: Carmel Utilities
Carmel Utilities 10/09
1 Civic Square
Carmel, IN 46032-
Invoice 251677
ProcCede -Date Descr iption Char e Recei t Adiusi oaiance
10/13/2009 Whisper Test 1.00 7.00 7.00
51002 10/13/2009 Urinalysis, Mini Dip w/ Physical 1.00 7.00 7.00
99173 10/13/2009 Snellen 1.00 7.00 7.00
99356 10/13/2009 DOT /PPCL Exam 1.00 53.00 53.00
Joseph W Faucett XXX -XX -6198 Balance Due: 74.00
10/13/2009 Whisper Test 1.00 7.00 7.00
S1002 10/13/2009 Urinalysis, Mini Dip w/ Physical 1.00 7.00 7.00
99173 10/13/2009 Snellen 1.00 7.00 7.00
993S6 10/13/2009 DOT /PPCL Exam 1.00 53.00 53.00
Blaine P Mallaber XXX -XX -1482 Balance Due: 74.00
Invoice 251677 Balance Due: 148.00
PLEASE REMIT PAYMENT PROMPTLY. THANK YOU
t W lil t 'a s�. at— ,�a��_
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
355031
COMMUNITY OCCUPATIONAL HEALTH Purchase Order No.
PO BOX 19383 Terms
INDIANAPOLIS, IN 46219 Due Date 11/30/2009
Invoice Invoice Description
Date. Number (or note attached invoice(s) or bill(s)) Amount
11/30/200 251677 $148.00
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
9 L
A47
Date Officer
ALLOWED
:VOUCHER 096818 WARRANT
355031 IN SUM OF
COMMUNITY OCCUPATIONAL HEALTI
PO BOX 19383
INDIANAPOLIS, IN 46219
Carmel Wastewater Utility
i ON ACCOUNT OF APPROPRIATION FOR
I�
Board members
PO INV ACCT AMOUNT Audit Trail Code
251677 01- 7362 -06 $148.00
U
Voucher Total $148.00
Cost distribution ledger classification if
claim paid under vehicle highway fund