177154 09/15/2009 f CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
q 0 ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH MK AMOUNT: $74.00
CARMEL, INDIANA 46032 P 0 BOX 19383
INDIANAPOLIS IN 46219 CHECK NUMBER: 177154
CHECK DATE: 9/15/2009
DEPARTMENT AC COUNT PO NUMBER IN VOICE NUMBER AMOUNT DESC
651 5023990 246954 74.00 OTHER EXPENSES
t
,r
Community Occupational Health Services
P.O. Box 19383
Indianapolis, IN 46219
317- 355 -6335
Tax ID 35- 1955223
Invoice
September 03, 2009
Bill to: Shelly Lingelbaugh For: Carmel Administration
Carmel Administration 8/09
1 Civic Square
Carmel, IN 46032
Invoice 246954
Proc Code Service Date Ues(!h tion Quantity G ar e Recelut dust Balance
82075 08/ 2009 reath A ohol Test 1.00 30.00 30. 0
\I Randall E Johnson XXX -XX -0132 Balance Due: 30.00
08/13/2009 Whisper Test 1.00 7.00 7.00
81002 08/13/2009 Urinalysis, Mini Dip w/ Physical 1.00 7.00 7.00
99173 08/13/2009 Snellen 1.00 7.00 7.00
99386 08/13/2009 DOT /PPCL Exam 1.00 53.00 53.00
Christopher A Stubbs XXX -XX -1295 Balance Due: 74.00
Invoice 246954 Balance Due: —4-04:08
PLEASE REMIT PAYMENT PROMPTLY. THANK YOU 1q. OD
Cut and return with payment
Please remit 104.00 to Community Occupational Health Services
Please place invoice number 246954 on check P.O. Box 19383
Indianapolis, IN 46219
Phone: 317 355 -6335
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER r:
CITY OF CARMEL r'
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 9/10/2009
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
9/10/2009 246954 $74.00
hereby certify that the attached invoice(s), or bill(s) is (are) true and
orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Of 4ce r
tVOUCHER 096387 WARRANT ALLOWED
355031 IN SUM OF
COMMUNITY OCCUPATIONAL HEALTI
PO BOX 19383
INDIANAPOLIS, IN 46219
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
246954 01- 7042 -06 $74.00
Voucher Total $74.00
Cost distribution ledger classification if
claim paid under vehicle highway fund