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170401 04/01/2009 CITY OF CARMEL, INDIANA VENDOR: 00352647 Page 1 of 1 ONE CIVIC SQUARE BRUCE GIPSON CHECK AMOUNT: $195.00 CARMEL, INDIANA 46032 1023 WOODBRIDGE CT CARMEL IN 46032 CHECK NUMBER: 170401 CHECK DATE: 4/1/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4343002 195.00 EXTERNAL TRAINING TRA i I of cagy;... CITY OF CARMEL Expense Report (required for all travel expenses) jNDIANP EMPLOYEE NAME: �5a DEPARTURE DATE: TIME: AJN PM DEPARTMENT: RETURN DATE: TIME: r AM PM REASON FOR TRAVEL Z��.,�..���� DESTINATION EXPENSES ARE FOR (check all that apply): TRAVEL ADVANCE TRAVEL REIMBURSEMENT TRAVEL PAR DIEM Transportation Gas/Tolls/ Meals Date Lodging Misc. Total Air -fare Car Rental Other Parking Breakfast Lunch Dinner Snacks Per Diem $0.00 3/13/09 $60.00 3/14/09 $60.00 3/15/09 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00 Total l- $0.00 $0.00. $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 e C DIRECTOR'S STATEMENT: 1 $r y ffi�t II expenses fisted conform to the City's travel policy and are within my.department's appropriated budget. Director Signature: Date: MAR 2 Z City of Carmel Form ER06 Revision Date 3/20/2009 Page 1 f U. S DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT See Reverse for O.M.B. No. 1660 -0007 GENERAL ADMISSIONS APPLICATION SHORT FORM Privacy Act Statement Expires Febnwy 28, 2007 USE THIS FORM ONLY IF APPLYING FOR NFA OFF CAMPUS COURSES (EXCLUDING REGIONAL DELIVERIES} SECTION I GENERAL INFORMATION 1. DAT$ OF BIRTH (Mo, Day, 2. SEX 3. U. S. CITIZEN Yes No If No, City and Cou Yr.} Female Male /X y try of Birth: 4a. ETHNICITY 4b. RACE (Please check all that apply) 1. HISPANIC or LATINO 1. kMERICAN INDIAN or ALASKA NATIVE 2. ASIAN 3. BLACK or AFRICAN AMERICAN 2. NOT HISPANIC or LATINO 4. X WHITE 5. NATIVE HAWAIIAN or PACIFIC ISLANDER 5. P1.l�ASE PRINT YOUR N t, First, Middle, Suffix) 7. MAILING ADDRESS (treM avenue, ro %�dtt no., city or town, and zip code) S. WORK PHONE NO. (3 j '7 j Z -1 i Gd G f 9. HOME PHONE NO. (3 1 q l j Z-0 2 3 �.4lLw1L-�i L �y 'U+ 3Z 10. FAX NO. 11. EMALL ADDRESS so ur I" -1 ✓l o o 12a. ENTER COURSE f CSJDE AND TITLE 12b. COURSE LOCATION 12c. COURSE NATE YL5P> .L S`f�lit= Ya /1:5 �1L f�'/� c--'l7,vaa ee 1. +I F4 0 14 C AI( -115 •l ��S.s, Z.+[r� 13. DO YOU HAVE ANY DISABILITIES (Inclqingjjxcial allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE AT NETC or MWEAC7 NO 5T YES (IJyes, indicate describe any special considerations required on a separate sheet) V SECTION I I EMPLOYMENT INFORMATION 14a. NAME AND COMPLETE ADDRESS OF RGANIZATION BEING REPRESENTED 14b. NFIRS## 15. CURRENT POSITION AND NUMBER 0- c�t2✓✓t L L l Qc: (NFA ONLY) IO OF YEARS IN P ^�7 Fl 'T ifyeeg /P gelz '7t 4/L C 466 3 10yrec 16. CHECK THE BO S BELOW THAT BEST DESCRIBE YOUR ORGANIZATION 16 .ORGANIZATION 16c. CURRENT STATUS 16a. JURISDICTION 1 1.�ALL CAREER 1. PAID FULL TIME 1. L] STATEWIDE 4. SPECIALDISTRICI'/TOWNSHIP/ 7 FOREIGN TRIBAL NATION L] 2. ALL VOLUNTEER 2. PAID PART TIME 2. F COUNTY GOVERNMENT 5. FEDERAL/MILITARY (non -DHS) 8 DHS/FEMA 3 COMBINATION 3. L1 VOLUNTEER TT 3. I� CITY/TOWN/VLLAGE 6. El INDUSTRY/BUSINESS 9. F] NDER/EMA 4. El DISASTER RESERVIST SECTION III ENDORSEMENT AND CERTIFICATION 17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001). 17b. I hereby authorize the release of any and all information conceminp my enrollment in this course to the chief officer in charge, or designee, of my organization. All requests for information shall be in writing from said chief officer or designee. 17c. Further, I understand that National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center "VEOC), and the Noble Training Center (NTC) are not authorized to provide medical or health insurance for students. I maintain appropriate Insurat:ce on an individual basis. 17d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC and NTC. Failure to do so will result in denial of the student stipend, expulsion from the course, and possible barring from futur ationel -£tire Academy (NF A) and Emergency Management Institute (EMI) courses. 18 IGNAT OF APP 186. DATE 19. APPROVAL BY HEAD OF SORING ORGANIZATION NOT RE UIRED FOR SELFSTUDYPROCR4Ms By signing this application, I certify That my organization does no iscriminate on the basis of age, sex, race, color, religious belief, national origin, economic status, or disability in providing educational opportunities for its employees. 19a. SIGNATURE 19 PRINTED NAME AND TITLE 19c. DATE 20. O ND E TION TO THE EMERGENCY MANAGEMENT INSTITUTE NOTR UIRED FOR SE STUDYPROGRAMI 20a. 7htWdf D Late ffice) 20b. SIGNATURE AND DATE (FEMA Regional Office) 21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR FEMA Form 75-5A, FEB 04 n REPLACES ALL PREVIOUS EDITIONS -i7,4( 4ocR7icacl l.'j -r�20 22a. DISPOSITION 22b. SIGNATURE OF REVIEWER 22c. DATE ACCEPTED REJECTED EQUAL OPPORTUNITY STATEMENT NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, race, color, religious belief, national origin, or disability in their admissions and student- related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified minority and women candidates are encouraged to apply for all courses. PRIVACY ACT STATEMENT GENERAL This information is provided pursuant to Public Law 93 -579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.), Section 552a, for individuals applying for admission to NFA or EMI. AUTHORITY Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seg. Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, Title 42 U.S.C., Sections 5121 et. seq. Title 44 U.S.C., Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights Act of 1964; and Section 5044 of the Rehabilitation Act of 1973. PURPOSES: To determine eligibility for participation in NFA and EMI courses. Information such as age, sex, and ancestral heritage are used for statistical purposes only. USES: Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a physician to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating programmatic statistics; 4) sponsoring states, local officials, or state agencies to update /evaluate statistics of NFA and EMI participants, 5) Members of Congress seeking first party information, and 6) Agency training program contractors and computer centers performing administrative functions. EFFECTS OF NONDISCLOSURE Personal information is provided on a volunteer basis. Failure to provide information on this form, however, may result in a delay in processing your application and/or certifying completion of the course. Information Regarding Disclosure of Your Social Security Number Under PL 93 -579, Section 7(b) E.O. 9397 authorizes the collection of the SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN. The SSN is used for record keeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not provide your SSN, another number will be substituted, which will delay processing of your application or course certificate. PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 6 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U. S Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. NOTE: Do not send your completed form to this address. Indiana Firefighter Training System rim Indiana Department of Homeland Security 302 W. Washington St. Indianapolis, IN 46204 February 2, 2009 All Registered Attendees for 2009 NFA Weekend Trip Re: Trip informational letter This letter will inform you what you will need to know for this year's trip out to the National Fire Academy. I first want to welcome you and I am looking forward to seeing you on the trip. We hope to have a good trip and all of you have a good experience out at the academy. Along with this letter I have attached the welcome package information from the NFA -EMI. If you have any questions on the trip, please contact me. Travel This year we have three buses to transport attendees out to the academy. One bus will leave from just west of the Auburn Fire Department in Auburn, IN. You need to park in the C &A Tool lot, address is 1015 West 15` Street, Auburn, IN. The bus Nvill leave at 6:00 am on March 13` Please be on the bus and ready to go by 6:00 am. There are two buses leaving from Greenfield Fire Department, 17 West South St., Greenfield, IN. The buses will leave at 6:OOam on March 13th. Park in the parking lot to the west of the fire station. Please be on the bus and ready to go by 6:OOam. The buses will stop twice on the way out and on the way back. You may want to pack a snack for the trip. The buses have DVD players on board so if you have movies for the trips please bring them. Make sure you have signed for a bus if you plan to ride. If you change plans please let me know. Dress Code The NFA has a dress code and will enforce it. All students must wear shirts with collars when attending classes. No sweatshirts can be worn in the classes. Shirts can be uniform, button down, or polo style shirts as long as it has a collar. Dress jeans or casual pants can be worn, NO sweat pants or shorts. There is no need for Class A or formal dress clothes. Dress for the weather as you will be outside at times while on the trip to the academy. Arriving at the NFA All attendees will need to have a state issued photo ID (Driver Licenses) with them. You need to report to Building ''C" once you arrive on campus for check -in. You will be assigned your room and receive your meal ticket at registration. You are eligible to eat dinner at the academy' on Friday evening. There will be a Mandatory Informational Meeting at 6:00 pm in building ".I EVERVONE must attend! Cancellations If you must cancel your trip, you need to contact me. Anyone registered for the trip and is a No Show will be charged $100.00 process fee and not be allowed to attend any NFA EMI courses for three years. Course Notice For those of you who signed up for the "Fire Behavior in a Single Family Residence" or "Comprehensive Fire Protection Approach in a Commercial Property" courses, the NFA staff has informed me that the two -day course material has not arrived yet. These courses will be one day courses and you will be able to complete both courses in one weekend. You do not need to do anything extra. Further information will be provided at the informational meeting on Friday evening. Cell phones use and texting while in class All phones must be turned off or muted while in class. No one will be allowed to text while in a class. Please advise your people that you will be unavailable during class time and you will return calls and texts at a later time. You may give them my phone number and they may contact me if there is an emergency and they need to reach you. Contact information My contact information is as follows. Steve Walters, NFA State Representative Office 317- 232 -2447 Cell phone 317 695 -1616 Email swalters tr,dhs.in. -,ov While on the trip I want to remind you are representing your fire department and as a group you are representing the State of Indiana. We ask that everyone be responsible and professional while on the trip. This trip is a great opportunity for you to experience the National Fire Academy. The 2009 Indiana NFA Weekend Trip is funded by the National Fire Academy and the State of Indiana through the State Firefighting Training Grant. Thanks Steve Walters State NFA Representative State Firefighting Program Manager Indiana Department of Homeland Security 2009 Indiana National Fire Academy Weekend Trip March 14 15, 2009 On the campus of the National Fire Academy, Emmitsburg, Maryland This year's trip will be sending 180 students to the National Fire Academy for a weekend trip FREE of charge. Course registration, rooms, and bus transportation will be provided at no charge to students. Don't miss out on this year's wonderful trip. The weekend trip offers a great opportunity to see the NFA and attend some great classes with great instructors. I this year, we will have three buses. Two buses will leave Greenfield and one bus will leave Auburn Indiana on March 13` You must include your preference in location on the bottom margin of the 75.5a application. (You will be advised of your pickup point.) (No guarantees on location) The buses seat 55 per bus. If you wish to drive out yourself, please indicate on the bottom of the 75.5a application. All approved students will receive confirmation letters and trip information by February 7 2009. Course information class status Command and Control of Wildland/Urban CCWUIFOSCO 30 seats open Interface Fire Operations for the Structural 612 Chief Officer Train- the Trainer Comprehensive Fire Protection Approach CFPA- 355 30 seats open in a Commercial Property Fire Behavior in a Single Family FBSFR 366 30 seats open Residence Leadership 1: Strategies for Company LS 1- 803 30 seats open Success Methods of Enhancing Safet}- Education NIESE 344 30 seats open Courtroom Preparation and Testimony for CPTFR 209 30 seats open First Responders Classes will be filled, first come first served, so get your applications in! For course details you may visit the NFA's website at http: /www.usfa.dhs.2ov /nfa /resident /swp /index.shtm 2009 Indiana National Fire Academy Weekend Trip Program sponsored by Indiana Firefighter Training System 4F Indiana Department of Security Anyone interested in `oin<, will need to reLIster by iillin <u out the F( !\/I 75.5a app]ICatlOn ple',1Se nrlllt Cleary' 111C1 I etLlrll It by Feb1 1, 2009 to; Indiana Department of Homeland Security Attn: Steve Walters 302 W. Washington St. E -208 Indianapolis, IN 46204 APPLICATIONS MUST BE FILLED OUT COMPLETELY AND SIGNED OFF. PLEASE PRINT CLEARLY SO WE HAVE YOUR INFORMATION CORRECTLY. Trip cancellations must be made by February 10, 2009 or the applicant will be charged $100.00 and not allowed to attend future weekend's trips for three years. (NFA rules) For additional information on the trip contact Steve Walters, State Firefighter Training Program Manager at 317- 232 -2447 or swaltersQdhs.in.gov The course is free, rooms are free, bus ride is free, and you eat for free while you are at the NFA. How great is that? MARK YOUR CALENDAR TODAY! Join us for the Indiana Weekend at the National Fire Academy. This setting will allow students from various parts of Indiana the opportunity to interact together in the classroom. All classes will be filled on a first come first serve basis. Return the completed application via fax to: (317) 234 -0736 or via regular mail by Feb. 1, 2009 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 service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Indiana Weekend Per Diem $180.00 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 N ALLOWED 20 Bruce Gipson IN SUM OF ,.$1.80'00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1120 43- 430.02 1 hereby certify that the attached invoice(s), or 1120 43- 430.02 $180:00 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 MAR 3 0 Z669 vd Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund