172891 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 00352344 Page 1 of 1
ONE CIVIC SQUARE INTERNATIONAL SOCIETY CHECK AMOUNT: $45.00
CARMEL, INDIANA 46032 OF ARBORICULTURE
P.O. BOX 3129 CHECK NUMBER: 172891
CHAMPAIGN IL 61826 -3129
CHECK DATE: 5/27/2009
DEPARTMENT :A PO NUMBER INVOICE NUMBER AMO DESCRIPTI
1192 4355300 45.00 ORGANIZATION MEMBER
INTERNATIONAL SOCIETY
OF ARBORICULTURE
CERTIFICATION PROGRAM
P,O, Eox 3129 Charnpaign, IL 61826 -3129 (217)355-9411 Fax (217) 355 -9516
email; CertQi��- a�i)orcc�m ni�'�ttt't: 17ttI� ;!!��'�'w.i��- ��if�r.Cc�m
RECERTIFICATION INVOICE
Please update my information. (make updates to your information below)
Name: Nichole Passineau Phone: (317) 650 -2863
Address: PO Box 831 Fax:
Address: Email: npassineau @yahoo.com
City, State: CICERO, IN Certification WI- 0692AT
Postal Code: 46034 Expiration Date 6/30/2009
Country: UNITED STATES
Member Recertification Fees
Certified Arborist NA
Utility Specialist NA
Municipal Specialist NA
Tree Worker /Climber Specialist $45
Board Certified Master Arborist NA
Tree Worker /Aerial Lift Specialist NA
TOTAL AMOUNT DUE (US Funds Only) $45
TOTAL DUE IN 30 DAYS
Please submit payment by:
Check: (number)
VISA
AM /EX Credit Card Number: Exp Date:
MASTERCARD
Name or Company Listed on Credit Card:
If you are receiving this invoice you have successfully met the CEU requirement needed to recertify. Paying this invoice is the
second and final step to recertification. This fee is paid every three years as your certification expires and you have obtained
the required CEUs.
If you would like to see your ending CEU total your CEU report is still available for viewing online. Also, if you would like to pay
this invoice with your credit card you have the option to now pay on the ISA website using the highly secured online
recertification form. A username and password is needed to access this portion of the website. If you don't already have a
username and password set up please contact us!
Check your CEU's onine: http: /www.isa- arbor.com /members /members.aspx
FOR OFFICE USE ONLY
Other:
Date Received:
Date Processed By:
Printed on: 5/5/2009
RB 1
isa
International Society of Arboriadture
P.O. Box 3129
Champaign, Illinois 61826 -3129
Certificant Ethics Representations and Agreements
(You must respond to each question)
1. I agree to act, and conduct my arboriculture services and activities,
in accordance with the current ISA Certified Arborist Code of
Ethics ISA Ethics Case Procedures and other applicable ISA YES NO
Certification Program policies, and as they may be amended or
revised.
2. I have not been, nor am I currently, the subject of any charge,
complaint, or conviction related to a criminal or quasi criminal YES NO
matter.
3. 1 have not been, nor am I currently, the subject of any formal
complaint or charge by a government or other regulatory body, YES NO
professional association, or certifying body.
4. I have not been found in violation of any law, regulation, or policy
by a government or other regulatory body, professional association, YES NO
or certifying body.
5. I have not been, nor am I currently, the subject of any other court or
governmental matter or proceeding, related to my professional YES NO
practice, or business activities.
6. I understand that any intentional or unintentional failure to provide
timely, accurate, and complete responses to this Application may
result in sanctions by the ISA Certification Program. YES Ai NO
(NOTE: IF YOU ANSWERED "NO" TO ANY QUESTION(S) ABOVE, YOU MUST
PROVIDE A COMPLETE, DETAILED EXPLANATION OF THE CIRCUMSTANCES
RELATED TO YOUR "NO" RESPONSE, AND THE FINAL DISPOSITION AND /OR
DECREE RELATED TO ANY MATTERS INCLUDED IN ITEMS 2, 3, 4, OR 5, ABOVE.
PLACE THESE MATERIALS IN A SEALED ENVELOPE MARKED "ETHICS" AND
STAPLE THE ENVELOPE TO YOUR APPLICATION. FAILURE TO INCLUDE THE
REQUIRED INFORMATION MAY DELAY THE PROCESSING OF YOUR
APPLICATION.)
1�
International Society IS A
P.O. Box 3129
Champaign, Illinois 61826 -3129
Certificant Certification Agreement/ Release Authorization
I acknowledge that I have read and understood all of the terms and conditions of ISA
certification, as set forth in ISA Certification Program policies.
I agree to provide the ISA Certification Program with written notice of any home or business
address, telephone, or e -mail change within sixty (60) days of such change. I understand and
agree that I am obligated to report to ISA, in writing, modifications to my application responses
in a timely, accurate, and complete manner, and no later than sixty (60) days of my knowledge.
I understand that ISA certification is conditioned upon my fulfillment of all required certification
and recertification requirements, including compliance with the ISA Certified Arborist Code of
Ethics I understand that the ISA Certification Program is separate and distinct from all other
Society programs and services, and that certification does not create membership or other similar
rights with ISA, including the right to use ISA trade /service marks or collective membership
marks.
I understand that any certification granted by ISA does not represent licensure, registration, or
other authorization to practice or to conduct business activities for a fee or otherwise. I agree to
indemnify and hold ISA and its agents, employees, representatives, and successors, harmless
against, and release them from, any and all claims, suits, complaints, losses, or liability (claims)
(including attorney fees) arising out of, or related to: ISA certification; my use and /or display of
ISA Certification Program credentials or designations, or references to the ISA Certification
Program; my professional activities and services; or, my other business activities.
I understand that ISA certification is personal to me, and may not be transferred or assigned to
any other individual, organization, or entity. With respect to my use and /or display of ISA
certification marks in connection with professional business activities, I agree to comply with all
applicable ISA policies, including ISA Certification Program Policy and Procedure Statement
No. 0016.
I agree to report, within sixty (60) days of my knowledge, the following court, governmental,
and professional organization matters related to me:
ISA Certification Program
Certificant Certification Agreement
Any charge, complaint, or conviction related to a criminal or quasi criminal matter.
Any formal complaint or charge by a government or other regulatory body, professional
association, or certifying body.
Any determination by a government or other regulatory body, professional association, or
certifying body concerning violations of laws, regulations, or policies, including any
sanctions, discipline, and /or corrective action issued by that body.
Any other court or governmental matter or proceeding, related to professional practice or
business activities.
I understand that professional biographical data is considered to be public information and will
be made available in response to consumer inquiries. I further agree that, for research and
statistical purposes only, data resulting from my participation in the ISA certification process
may be used. I understand that all material becomes the property of ISA upon receipt and that
neither originals nor photocopies will be returned to me.
In the event that my ISA certification is suspended or revoked, I agree to: comply with all
directives or orders of the ISA Certification Board, ISA Ethics Review Committee, and /or ISA
Certification Program, including the return of all ISA credentialing documents, in a timely
manner and at my own expense; and, immediately stop all use of the ISA Certified Arborist
certification mark, credential, or any other designation indicating an affiliation with ISA.
X�rjo'a &M� <5113 10 7
Signature of Ce ficant Date
N t�o(e �gz1aQacc.. These documents must be signed
Printed Name of Certificant and returned to the ISA
Certification Program within thirty
(30) days of the date of this
correspondence.
ISA Certification I.D. ISA Certification Department
PO Box 3129
Champaign, IL 61826 -3129
Fax: (217) 355 -9516
Email: cert@isa- arbor.com
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))
05/13/09 Dues Nichole $45.00
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
International Society of Arboriculture
Certification Program IN SUM OF
P.O. Box 3129
Champaign, IL 61826 -3129
$45.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1192 43- 553.00 $45.00 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
Friday, May 22, 2009
16 1rector, D S
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund