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HomeMy WebLinkAbout168941 02/17/2009 CITY OF CARMEL, INDIANA VENDOR: 362575 Page 1 of 1 is ONE CIVIC SQUARE THE DIFFICULT AIRWAY COURSE -EMS CHECK AMOUNT: $700.00 CARMEL, INDIANA 46032 4145 JAMES CARPENTER LANE MAIDEN NC 28550 CHECK NUMBER: 168941 CHECK DATE: 2117/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4357004 700.00 EXTERNAL, TNSTRUCT FEE S z •5" {fib, 6 .,k'i fit`" «"�.u• .�"lE..�2`,a r t e #'a"� �''tC t 'd*_Y k�`^k.z"� a �rWVUU thaairwaysite c RM e e. s `h asc r m y- -`YP a r' ';:.C,.....sxxxaua+ane.,x Nd waa x �ux-ta Reg istration F orm Contact Information Name Home Street Address 1/7 q Te, Home Cit State, ZIP Cod r ifC'T'�5 _11� 5!6v!� Preferred Phone Number 30 9 3 ce ©cat Email Address �fJhE/�CrE�+S GdrrC:al: r LicenselCertification Information (Req for EMS Provi ders) Job Title rF em Ag ency /Employer G2,4AMe "iF2Lr v: State License Number L C, �Lc! g State License or Certification Level Example: EMT -P IF/- 7— State of Licensure,�,;,��_� State License E xpiration Date i on/ �01 NREMT Certification N umber NREMT Re- registration date N� Which Course W ill You Be Attendin Course Date Course Lo cation Course Tuition ($375 in Western Region /$350 in all other regions__ H ow Will Y Be Pa ying Select one Check o Cred Card Amount to be charged Type of card o Visa o MasterCard o Other (please specify): o N Card Number Expiration Date Name on Card Securit Card Code Signature a '°'Y.:` w'�" A` R Form Con In fo rma tion Name Home Street Address 3 i VP rl/ Piz 1z15 6 ff Home City, State, ZIP- Preferred Phone Number Email Address Li'censelCer#ification Inform for EMS Prov Job Title FF)1�, A gency /Employer l Dr ��r2r t2 D State License Number State License or Certification Level (Example: EMT- P)_ State of Lice State License Ex piration Dat L 0�_ �'�►0 NREMT Certification Number ED q NREMT Re reg istration date Whic Cou rse WHUYou`Be Attendi Course Date R a ,?-8 Course Location Course Tuition ($375 in Western Region /$350 in all oth re gions Hb You Be Pa cog Select one Check c Credit Card Amount to be charg Type of card o Visa o MasterCard o Other (please specify): o NIA Card Number Expiration D ate Name on Card Security Card Code Signature l �aaar� a :A.. %"TINY :.v wC'a u"'4 r�+r '4� a .ate i' �iwi et+v, Etl'` Y �`�r'rn.•, °r�:mit �F� rn�- a5+ v t-- ,�mxr' :FFr�''"s xe+ q„a ��u+. w. a,.s "r'��rxr^1eY�fi .u,:.�.�„ '.�.c�'e-�- "'''`�v�x. ..�s•��i xe a �r� ��?s a e V���� '•n 7' �u f�LN ri rc' "`�,�'Y f W.'Tr wvMaG X "s ti em d www th rrwayi #e xis.• .w` :'ue$1'1" :v4.. ,c�"u` e� a Y" w r J J k �Rl ✓ter ���w p"tlrarrr 'm",. s rnr✓a+t -s. T:-'a* :mr whw nex?. Instructions for Mail -in or Fax -in Registrations 1. Fill in the required information on the registration form. 2. Print the form. 3. Mail the form to the appropriate registration office (see below) with a check for the tuition. If you fax in your form, please send a check to the appropriate registration office (see below). 4. A $50 fee will be assessed for returned checks. Regional Registration Offices Western Region (WA, OR, CA, ID, NV, MT, WY, UT, AZ, CO, NM): The Difficult Airway Course EMS'" Registrations Toll -Free: (866) 924 -7929 333 South State Street, Suite V324 Fax: (404) 795 -0711 Lake Oswego, OR 97034 Visa, MasterCard and Discover accepted. Please make checks payable to "The Difficult Airway Course EMS." Northeast Region (NY, CT, RI, MA, VT, NH, ME): The Institute for Pre hospital Education and Training Phone: (631) 444 -6072 Stony Brook University Medical Center Fax: (631) 444 -6233 Nicolls Road Stony Brook, NY 11794 -8350 ATTN: Colby Rowe, EMT- P /FP -C Please make checks payable to "Stony Brook University Medical Center Emergency Medicine." Credit cards accepted for on -line registration only. Mid- Atlantic Region (PA, NJ, DC, MD, DE): The Difficult Airway Course EMS'' Registrations Toll -Free: (866) 924 -7929 333 South State Street, Suite V324 Fax: (404) 795 -0711 Lake Oswego, OR 97034 Visa, MasterCard and Discover accepted. Please make checks payable to "The Difficult Airway Course—EMS." Southeast Region (NC, SC, VA, GA, WV, FL, OH, KY and TN Nashville and East): The Difficult Airway Course —EMS"" Phone: (336) 880 -4552 4145 James Carpenter Lane Fax: (336) 869 -6026 Maiden, NC 28650 Email: difficultairwayems @gmail.com Visa and MasterCard accepted. Please make checks payable to "The Difficult Airway Course EMS." Gulf Coast Region (AL, MS, AR, LA, TX, TN West of Nashville): Anesthesia Clinical Educational Services Toll -Free: (888) 774 -8823 36332 Cypress Glen Fax: (225) 673 -5069 Prairieville, LA 70769 Visa, MasterCard, and Discover accepted Please make checks payable to "Anesthesia Clinical and Educational Services." Midwest Region (MI): Registration being handled by the Southeast Region (see above). TheAirwaySite a CLASS DATES Airway Manangement Education Center Page 1 of 11 February 12, 2009 Welcome Guest! Login HOME CLASS DATES SCHEDULE REGISTER FACULTY CONTACT BROCHURES AIRWAY Q &A Dates and Locations for The Difficult Airway Course: EMS Registration for The Difficult Airway Course: EMSTM is handled by regional registration offices. Registration and con information is provided for each course listed below. February 7 8, 2009 Hackensack, N7 Hackensack University Medical Center 30 Prospect Avenue Hackensack, NJ CI For Course Registration and Information: m The Difficult Airway Course: EMS (Mid Atlantic Region) re On -line: Click on Register button Tall Free: (866) 924 -7929 Direct: (503) 635 -4761 Fax: (404) 795 -0711 February 21 22, 2009 Ocean County, N] Ocean County Fire Academy and Training Center New Course! Route 9 Volunteer Way Waretown, NJ 08758 Directions For Course Registration and Information: The Difficult Airway Course: EMS (Mid Atlantic Region) Cl m re_ On -line: Click on Register button Toll Free: (866) 924 -7929 Direct: (503) 635 -4761 Fax: (404) 795 -0711 http: /www.thcairwaysite.com /Class %20Dates CLASS %20DATES_Difficult- EMS.php 2/1.2/2009 TheAirwaySite CLASS DATES Airway Manangement Education. Center Page 4 of 11 5505 Rybolt Road Cincinnati, OH Phone: (513) 574-6000 Date: TBD Norfolk, VA Norfolk Fire Rescue Academy The new date for this course will be announced soon! 7120 Granby Street Norfolk, VA 23505 Cl- m For Course Registration and Information: re_ The Difficult Airway Course: EMS (Southeast Region) fo.. Phone: (336) 880 -4552 Fax: (336) 869-6026 Recommended Hotels April 25 26, 2009 Geneva, 'NY Finger Lakes Community College 63 Pulteney Street Geneva, NY C For Course Registration and Information: m Institute for Pre Hospital Education and Training re On -line: Click on Register button Registration Line: (631) 444 -7822 Email: colby.rowe@stony_brook.edu April 27 28, 2009 Kalamazoo, MI Gilmore Health Education Center /Bronson Methodist Hospital 7 Healthcare Plaza CI Kalamazoo, MI m re For Course Registration and Information: fo The Difficult Airway Course: EMS (Midwest) Phone: (336) 880 -4552 Fax: (336) 869 -6026 Registration for this new Midwest course is being handled by our Southeast Region. For mailing address, please see Southeast Region on the mail -in /fax -in registration form. May 1 17, 2009 Hanover, PA http:// www. theairwaysite .com/Class %20Dates/ CLASS %20DATES_Difficult- EMS.php 2/12/2009 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)) Registration Fees Fisher, Rohr $700.00 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. ALLOWED 20 The Airway Course EMS IN SUM OF 4145 James Carpenter Lane Maiden, NC 28650 $700.00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members 1 120 43- 570.04 $700.00 1 hereby certify that the attached invoice(s), or 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 rXQ 1 220M n Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund