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170421 04/01/2009 CITY OF CARMEL, INDIANA VENDOR: 00352934 Page 1 of 1 F ONE CIVIC SQUARE ADAM HARRINGTON CARMEL, INDIANA 46032 19546 TRADE WINDS DRIVE CHECK AMOUNT: $195.00 NOBLESVILLE IN 46060 CHECK NUMBER: 170421 CHECK DATE: 4/112009 16EPARTMENT ACCOUNT PO NUMBER I NVOIC E NUMBER AMOUNT DESCRIPTION 1120 4343002 195.00 EXTERNAL TRAINING TRA el CITY OF CARMEL Expense Report (required for all travel expenses) alb \NOIPNP� EMPLOYEE NAME:v��� ��a-C� '-r DEPARTURE DATE: TIME: A ,'PM DEPARTMENT: RETURN DATE: y`v o TIME: A PM REASON FOR TRAVEL ti��it-- ---�J� DESTINATION CITY: EXPENSES ARE FOR (check all that apply): TRAVEL ADVANCE TRAVEL REIMBURSEMENT TRAVEL R DIEM Date Transportation Gas/Tolls/ Lodging Meals Misc. Total Air -fare Car Rental Other Parking Breakfast Lunch Dinner Snacks Per Diem; $0.00 3113109 $60.00 3114109 $60.00 3115109 $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 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 o DIRECTOR'S STATEMENT er affi hat �expens conform to the City's travel policy and are within my department's appropriated budget. MAR 2 0 2009 Director Signature: Date: City of Carmel Form ERo6 Revision Date 3/20/2009 Page 1 U. S DEPARTMENT OF HOMELAND SECURITY O M 13. Na 1ss0 0tloa FEDERAL EMERGENCY MANAGEMENT See Reverse for Privacy Act Smatemad Expires February 28 26V7 GENERAL. ADMISSIONS APPLICATION SHORT FORM USE THIS FORM ONLY IF APPLYING FORNFA OFF CAMPUS COURSES (EXCLUDING REGIONAL DELIVERIES) SECTION I GENERAL INFORMATION 1. DA OF BIRTH o, Day, 2. SEX Yr.) Female M Male 3. U. S. CITIZEN N Yes No If No, City and Country of Birth: 4a. ETHNICITY 4b. RACE (Please check all that apply) 1. ❑I HISPANIC or LATINO i_ ANIEWCAN INDIAN or ALASKA NATIVE 1 ASIAN 3. BLACK or AFRICAN AMMUCAN 2. �Q NOT HISPANIC or LATINO 4. V WINE J. NATIVB HAWAIIAN or PACIFIC ISLANDER 5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix) 6. SOCIAL SECURITY NO A)CL C i 7. MAILING ADDRESS (Street, avenue, road no., city or town, and zip code) g. WORK PHONE NO. j 17 qq Z_ 31 L. t 195Ni ffad ewr ndS I)r 9. HOME PHONE NO. ygz- 31 GL IJobILs� -rN �Epto� l 0, FAX NO. (3 1 7 5 7 1' Z L b 9 11. EMAIL. ADDRESS e� k o, rf +t 40 rt t a rr1 c t i rt III 12a. ENTER COURSE CODE AND TITLE 5� racy r e; 1' r l 2b. COURSE LOCATION 12c. COURSE DATE L5 S-U brtJerykl I' ComfOL'ty 5n.errcf5 A(A- CMMi4ftk6 Mb MArek 11 ZD0`� 13. DO YOU HAVE ANY DISABIUTIES (Includi ecial allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE AT NETC or MWEAC? N0 YES g yes, indicate describe any special considerations required on a separate sheet) SECTION I I EMPLOYMENT INFORMATION 14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED 14b. NFLRS1l 15. CURRENT POSITION AND NUMBER L' r 4 y o CA -'M e I F. rc c j V (NFA ONLY) OF YEARS IN POSITION Z C Y V r_Z y 7 Ca 'reKt I �1J gb 03Z Flrc�1 16. CHECK THE BO S BELOW THAT BEST DE SCRIBE YOUR ORGANIZATION 16b. ORGANIZATION 16c. CURRENT STATUS 164. lIIRISDICTION 1. 3� CAREER 1. _!�J` PAID FULL TIME 1. STATEWIDE 4. SPECLAI.DISTRICTITOWNSHLP/ Li TRIBAL NATION 7. FOREIGN 2. ALL VOLUNTEER 2. PAID PART TAME 2. COUNTY GOVERNMENT S. FEDERAUNID.TTARY (non -0115) 8. DHS /FEMA 3. COMBINATION 3. ❑VOLUNTEER 3,_;t /TOWN/VILLAGE 6. INDUSTRY/BUSINFSS 9. NDERIAMA 4. 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 concerning 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 OX"OC), and the Noble Training Center (NTC) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. 11d. 1 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 baring from future National Fire Academy (NFA) and Emergency Managemenk Institute (EMI) courses. 18a. SIGNATURE !ENDORSEMEN NT 18b. DATE PROVAL BY HEAD OF THE SPONSORING ORGANIZATION OT RE LIMED FOR SELFS7VDYPR0GRAMS By signing 's ify that my izalian Acs riot discriminate on the basis of age, sex race, color, religious belief, national origin economic status, or disabitiky' dopp sties f S es. 192. S 19b. PRINTED NAME AND TITLE 19c. DATE 20. ADDITIONEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTIT[T E OT RE UIRED FOR SELF STUDYPROG SIGNATURE (Stale Office) 20b. SIGNATURE AND DATE (FEMA Regional Office) 21. SUBMIT APPL APPROPRIATE SPONSOR FEMA Form 75 -5A, FEB 04 REPLACES ALL PREVIOUS EDITIONS 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 ofage, 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 552x, 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. sea. Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, Title 42 U.S.C., Sections 5121 et. sea. Title 44 U.S-C., Section 3101; Executive Orders 12127, 12148, and 9397; Title VI ofthe Civil Rights Act of 1964; and Section 5044 ofthe 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 ofthe 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 ofthe course. Information Regarding Disclosure of Your Soclal Seturtly Number Under PL 93 -579, Section 7fbl E.O.9397 authorizes the collection of the SSN. The SSN is necessary because ofthe 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 ofthe SSN is voluntary. However, ifyou 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 ofthe 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 forum to this address. 1 Indiana Firefighter Training System 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 will leave at 6:00 am on March 13 th 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 1D (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 i% he a Mandatory Informational Meeting at 6:00 pm in building ",1 EVERYONE 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. PIease 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 swalte:s(c�,dhs.in.gov 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. N E b1' t1t is 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 I: Strategies for Company LS I 803 30 seats open Success Methods of Enhancing Safety Education MESE 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.gov /nfa /resident /swp /index.shtm 2009 Indiana National Fire Academy Weekend Trip Program sponsored by Indiana Firefighter Training System 9 ir Cndiatla Department of Homeland Security Anyone aoinu %\ill need to rea'ster b` tillinL exit the FIIiVI:'1 75.5a application please print clear IN WICI return it by FebI11,11 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 5100.00 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 swaltersgdhs.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'Neekend 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. WARRA NO. ALLOWED 20 Adam Harrington IN SUM OF 1 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 $1.80`00 bill(s) is (are) true and correct and that the s L LC materials or services itemized thereon for which charge is made were ordered and received except MAR _3 0 2009 s Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund