173776 06/24/2009 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH CHECK AMOUNT: $360.00
0 CARMEL INDIANA 46032
P 0 BOX 19383
INDIANAPOLIS IN 46219 CHECK NUMBER: 173776
CHECK DATE: 6/24/2009
DEPARTMENT A CCOUNT P O NUMBE INVOICE NU MBER AMOUNT DESCRIPTION
1046 4340700 233265 270.00 MEDICAL FEES
1125 4340700 233265 90.00 MEDICAL FEES
r�.
Community Occupational Health Services
s P.O. Box 19383
Purchase Indianapolis, IN 46219
Description Eny[cu(xwcPbrM 317- 355 -6335
P.O. P or F ID 35- 1955223
G.L. X q y y 6 "7 0 JUN 16 2009
Budg c `..Q S
Line Descr By.
Purchaser Datej�u f 0
Approval Dat Invoice
d5 0U ODC March 0? 2009
0 5 y ;0 q�
Bil to: Lynn Russell Lk For: Carmel Clay Parks Recreation
Carmel Clay Parks Recreation 2/09
1411 E. 116th St.
Carmel, IN 46032-
Invoice 233265
P roc Code Service Date Description Quantitv Charge Recei t Adiust Balance
'Q-,0101 02/19/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 b R 45.00
Christina L Fitch Balance Due: 45.00
50101 02/06/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 1 Tl I 45.00
Serra Garske Balance Due: 45.00
,:01 O1 02/05/2009 Dr
Screen Non NIDA 5 Panel 1.00 45.00 45.00
Stephen W Groce Balance Due: 45.00
30101 02/20/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 l0 45.00
Jordan W Hill Balance Due: 45.00
�0101 02/04/2009 Drug
Screen Non NIDA 5 Panel 1.00 45.00 L} r 45.00
Ashley A Livingston Balance Due: 45.00
0101 02/06/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 45.00
Katey M Lopez Balance Due: 45.00
°0101 02/03/2009 Drug Screen Non NIDA 5 Panel 1.00 45.00 I I 45.00
C7 t
Janna Water Balance Due: 45.00
St0 101 02/04/2009 Ding Screen Non NIDA 5 Panel 1.00 45.00 I� 45.00
Tiffany N Young Balance We: 45.00
Invoice 233265 Balance Due: 360.00
PLEASE REMIT PAYMENT PROMPTLY. THANK YOU
M1 Cut and return with payment
Please remit 360.00 to Community Occupational Health Services
Please place invoice number 233265 on check P.O. Box 19383
Indianapolis, IN 46219
Phone: 317- 355 -6335
ACCOUNTS PAYABLE VOUCHER
4 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.
355031 Community Occupational Health Services
Terms
P.O. Box 19383
Indianapolis, IN 46219
Invoice Invoice Description PO Amount
Date Number (or note attached invoice(s) or bill(s))
90.00
3/3/09 233265 Pre emp loyment drug testing 270.00
3/3/09 233265 Pre employment drug testing
Total 360.00
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
Voucher No. Warrant No.
355031 Community Occupational Health Services Allowed 20
P.O. Box 19383
Indianapolis, IN 46219
In Sum of
360.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund 104 Program fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1125 233265 4340700 90.00 1 hereby certify that the attached invoice(s), or
1046 233265 4340700 270.00 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
18 -Jun 2009
Signature
360.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund