177730 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: 361255 Page 1 of 1
ONE CIVIC SQUARE CARRIE KEAVENEY CHECK AMOUNT: $238.00
CARMELJNDIANA 46032 13789 FIELDSHIRE TERRACE
WESTFIELD IN 46074 CHECK NUMBER: 177730
CHECK DATE: 9/29/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1047 4357004 REIMB 238.00 EXTERNAL INSTRUCT FEE
.d
Carm
Darks &Recreati ®n
Employee Expense Reimbursement Request
Date of Fund Account Account
Receipt Vendor listed on receipt it Line Budget Description Amount Purpose of Expense
8/21/2009 ACE (Amer Council on Exercise) 47 47.400.100.4357004 Instructional Fees external $159.00 renewal of group fitness cert.
8/21/2009 ACE (Amer Council on Exercise) 47 47.400.100.4357004 Instructional Fees external $79.00 renewal of personal trainer cert.
All receipts should be attached in the same order as listed above.
No sales tax will be reimbursed. TOTAL: $2
Employee Name (print) Carrie Keaveney
Address 13789 Fieldshire Terrace �x
Check LS 0 4 2009
payable to: City, St, Zip Westfield IN 46074
Signature: ccu I Approved by:
Date: 8/31 /200 Date: 91"V
Business Services Division, Revised 7 -7 -08
FILE: Shared\Administrative \Forms \Staff Forms \Employee Exp Reimb Request
a GO PAPERLESS!; I
1004b
Aird E, Certification Renewal Form
Please fill in the information requested below.
AMERICAN COUNCIL ON EXERCISE4
Incomplete or unsigned renewal forms will not be processed.
Allow 4 to 6 weeks for your card and certificate to arrive.
Name Qarr"Z <Q_(Xueneul ACE Certification Number I O(a U6
Address 13�Z 9 Fi.IJSV Ire
City we _s ie.(4 State ZIP /Postal Code 46 0 7
Phone 6( (q a1C 5(o I I Fax E -mail CkQ_cW Q one_ Cad i nr(
D Check here if this is a new address.
Continuing Education Requirement
All existing and newly ACE certified Professionals must complete a total of 2.0 (20 hours) CECs every two years to renew your certification.
If you hold multiple ACE certifications, each will be subject to the above guideline dependent upon their individual expiration date(s)
List completed courses (Note: non ACE approved courses need to be petitioned)
Enclose transcript or grade report for eligible college course. Do not send original certificates.
Date: ACE Approved Course Course Title: Provider Name: CECs:
Example: 1/1/00 CP10010 Prof. Svcs. Training ACE Fitness 1.0
lohT 01 17 T3`13 Cub T"dvstr -_L602� e(ub .J- hd?ktsft 1.3.
o C.EP AEG A tre -r RQJ SS
0q e,E 1-71 0 fz
0 1 d f (ra,, F
U 0. J -P1S�. Inr A n
,1 Gr F. WI �rn x_u)
CPR must be current upon renewa Expiration Date S 1 Card Issued by /gym rice n N MS-S
Online CPR courses are not accepted. Effective January 1, 2009, all new and renewing ACE certified Professionals in the U.S.
and Canada must hold a current CPR and AED card.
Renewal Fee (see reverse)
Total enclosed: f S9 (A) (non refundable)
D Check (please make payable to ACE in U.S. funds)
D Mastercard Exp. Date CVC
Abisa S 1 0 Exp. Date _29�, CVC
D American Express Exp. Date CVC
I accept and agree to adhere to the American Council on Exercise® (ACE®) Code of Ethics and the Professional Practices and Disciplinary Procedures. I
hereby certify that the information contained on this renewal is true, complete and correct. I agree to release to ACE any information relevant to my re-
certification. I further understand if any of this information is later determined to be false, the American Council on Exercise reserves the right to revoke
any certification that has been granted on the basis hereof. 1 further understand that ACE certification does not certify or in any way guarantee the qual-
ity of my work as an ACE certified Professional. I therefore agree to indemnity and hold harmless ACE, its officers, directors and staff from any claims
due to negligence, omission or faulty advice that I may give to clients as an ACE certified Professional. I understand that ACE is not responsible for any
actions or damages from any person arising out of my work as an ACE certified Professional.
c' 9
Signature Date
Either mail to ACE, Attn: Certification Renewal, 4851 Paramount Drive, San Diego, CA 92123
OR fax to (858) 279 -8064
M09 -014
GO PAFERLESS! I
F 1004b
Certification Renewal Form
Please fill in the information requested below.
AMERICAN COUNCIL ON E%ERCISE4 Incomplete or unsigned renewal forms will not be processed.
Allow 4 to 6 weeks for your card and certificate to arrive.
Name o ct r r l c ACE Certification Number
Address 13 719 6 0-19sk Ire TcrraCe
City C1)Qs t-r-Q Q State lid ZIP /Postal Code WDO
Phone (bi a`)0 t6 1 "1 Fax L E -mail I Keav e.neQ r ncf V r r cor
Check here if this is a new address.
Continuing_ Education Requirement
All existing and newly ACE certified Professionals must complete a total of 2.0 (20 hours) CECs every two years to renew your certification.
If you hold multiple ACE certifications, each will be subject to the above guideline dependent upon their individual expiration date(s)
List completed courses (Note: non ACE approved courses need to be petitioned)
Enclose transcript or grade report for eligible college course. Do not send original certificates.
Date: ACE Approved Course Course Title: Provider Name: CECs:
Example: 1/1/00 CP10010 Prof. Svcs. Training ACE Fitness 1.0
Id (8 10 9 CP (9g (n dusfr x-W o (v �fncLust' q
1 3 0 111 (0 ED of
CP QQ_rf i rt caf 1M Arnz te,4 Cross
a 6 Cep ')a'4 Fi r'Sf r c Q C o s o
�0 0s Prc:cf; U o. lnsfi t FqA v
ap U r o'cfr r-J PI aht -S N jnt 4 0 A FFI iq
d-
0 9 CA 1G 5 -6 K G irp 64 homi r 3cct� a
CPR must be current upon renewal Expiration Date S a0 (0 Card Issued by /A
Online CPR courses are not accepted. Effective January 1, 2009, all new and renewing ACE certified Professionals in the U.S.
and Canada must hold a current CPR and AED card.
Renewal Fee (see reverse)
Total enclosed: 1�1 7q• U0 (non refundable)
Check (please make payable to ACE in U.S. funds)
Mastercard Exp. Date CVC
X visa 4J=Z Exp. Date ;;Rk CVC
American ExpreEs Exp. Date CVC
I accept and agree to adhere to the American Council on Exercise® (ACE Code of Ethics and the Professional Practices and Disciplinary Procedures. I
hereby certify that the information contained on this renewal is true, complete and correct. I agree to release to ACE any information relevant to my re-
certification. I further understand if any of this information is later determined to be false, the American Council on Exercise reserves the right to revoke
any certification that has been granted on the basis hereof. I further understand that ACE certification does not certify or in any way guarantee the qual-
ity of my work as an ACE- certified Professional. I therefore agree to indemnify and hold harmless ACE, its officers, directors and staff from any claims
due to negligence, omission or faulty advice that I may give to clients as an ACE certified Professional. I understand that ACE is not responsible for any
actions or damages from any person arising out of my work as an ACE certified Professional.
Signature Date
Either mail to ACE, Certification Renewal, 4851 Paramount Drive, San Diego, CA 92123
OR fax to (858) 279 -8064
M09 -014
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.
361255 Keaveney, Carrie Terms
13789 Fieldshire Terrace
Westfield, In 46074
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
8/21/09 Reimb Renewal of group fitness /personal trainer cert. 238.00
Total 238.00
1 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.
361255 Keaveney, Carrie Allowed 20
13789 Fieldshire Terrace
Westfield, In 46074
In Sum of
238.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1047 Reimb 4357004 238.00 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
24 -Sep 2009
U &NLIM12Uh�
Signature
238.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund