170799 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH ggEERR
K AMOUNT: $172.00
CARMEL, INDIANA 46032 M
P O BOX 19383
INDIANAPOLIS IN 46219 CHECK NUMBER: 170799
CHECK DATE: 4/16/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION
x '1046 4340700 228975 129.00 MEDICAL FEES
11047 4340700 228975 43.00 MEDICAL FEES
Community Occupational Health Services
P.O. Box 19383
Indianapolis, IN 46219
317- 355 -6335 lP.06
Tax ID 35- 1955223
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1pu- ��o� y .O
46_I L
Invoice
January 02, 2009
�B; iI to: Lyme Russell For: Cannel Clay Parks Recreation
Cannel Clay Parks Recreation 12/08
1411 E. 116th St.
Cannel, IN 46032-
Invoice 228975
P- oc Code Service Date Description Quantity Charge Receipt Adiust Balance
30101 12/11/2008 Drug Screen Non NIDA 5 Panel 1.00 43.00 43.00
Melissa S Jenniges Balance Due: 43.00
81101 12/11/2008 Dru g Screen Non NIDA 5 Panel 1.00 43.00 43.00
Denisse M Jensen Balance Due: 43.00
8 X101 12/02/2008 Drug Screen Non NIDA 5 Panel 1.00 43.00 43.00
Charlsie A Krauss Balance Due: 43.00
8 -101 12/04/2008 Ding Screen Non NIDA 5 Panel 1.00 43.00 43.00
Steven H Surgoth Balance Due: 43.00
Invoice 228975 Balance Due: 172.00
THIS IS A REMINDER THAT NEW RATES WILL GO INTO EFFECT FOR
SERVICES RENDERED AFTER JANUARY 1,2009. FOR QUESTIONS, PLEASE
CONTACT YOUR ACCOUNT MANAGER. THANK YOU
APR 0 6 2009
BY:
Cut and return with payment
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.
355031 Community Occupational Health Services Terms
P.O. Box 19383
Indianapolis, IN 46219
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
1/2/09 228975 Pre employment drug testing 129.00
1/2/09 228975 Pre employment drug testing 43.00
Total 172.00
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
r
In Sum of
172.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program fund
PO# or INVOICE NO. ACCT WTITLE AMOUNT Board Members
Dept
1046 228975 4340700 129.00 1 hereby certify that the attached invoice(s), or
1047 228975 4340700 43.00 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
9 -Apr 2009
W ha*Y=1
Signature
172.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund