HomeMy WebLinkAbout169088 02/17/2009 CITY OF CARMEL, INDIANA VENDOR: 216300 Page 1 of 1
ONE CIVIC SQUARE NATL ASSOC OF EMERG MEDICAL TEC E
0 CHECK AMOUNT: $40.00
CARMEL, INDIANA 46032 Po aox taoo
CLINTON MS 39060 -1400 CHECK NUMBER: 169088
CHECK DATE: 2/17/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4355300 40.00 ORGANIZATION MEMBER
,t`
National Association of Emergency Medical Technicians
PO Box 1400
Clinton, MS 39060 -1400
Physical Address:
132 -A East Northside Dr.
Clinton, MS 39056
Phone: 601-924-7744
Toll Free: 1- 800- 34 -NAEMT
Fax: 601 924 -7325
info(a)naemt.org
Membership Application
Fields with a are required.
Application Type NEW
First Name Mark
Middle Initial
Last Name Hulett
Suffix r
City of Carmel Fire Department
Organization Please enter the name of your Association affiliated
with NAEMT
Address 2 Civic Square
City Carmel
State /Province Indiana
Postal Code 46032
Country USA
M
Gender`
F
Phone 17- 571 -2663
Alternate Phone 17- 571 -2600
Fax 17- 571 -2615
E -mail n @carmel.in.gov
Secondary E -mail medichuey @aol.com
Date of Birth 10 24 195
MM DD YYYY
Address Type
Home
t:
Work
Expiration: 1 10 -1 -2010
State Certification No. PSID4145 -8312 ex: mm/dd/yyyy
Certification State: Indiana
and /or National Registry Expiration:
No. ex: mm/dd/yyyy
Country/Other Cert#: I r Expiration:
ex: mm/dd/yyyy
Check ONE in each column.
Training Level /Position Participation Employer /Affiliation
t~ fi
EMT -13 Volunteer Fire Dept.
EMT -Int Part-Time Private Ambulance
EMT -P Full -Time Third Serv. /Mun. Agency
Certified First Responder Hospital
t' t^
Physician Military
Medical Director Police Dept.
Nurse Individual
t: fi
Admin /Supervisor Rescue Squad
fi f'
Retired Health Agency
Other Industrial /Commercial
f
Other
Select type of membership:
t:
Individual Membership: $40 annual dues
f Affiliate Discount: $30 annual dues must be a member of an association affiliated with NAEMT
Military Discount: $25 annual dues must be E -5 or below.
i'
Student (EMT Program) Membership: $25 for one year only
National EMS Chiefs, Officers Administrators Instructor /Coordinator fV0 Paramedic
r Military r Industrial r Special Ops
F International
Military Only
Rank (E5 or below) Select a Rank
Active
l'
Reserve
Branch
f Air Force :r Army t' Coast Guard C Navy
r Marine Corps
Other I
Promotional Code:
All fees are payable in US Dollars
Total Due: $F 40
Please tell us who referred you to NAEMT:
NAEMT Member: I WA
OR Please enter either a member or affiliate organization, not both.
NAEMT Affiliate Organization: PhffLS
Select credit card type: �7 Visa fi M/C f" AmEx
Name on Card:
Card No.
Cwt F_
What is Cw2?
Expiration Date 01 2009
ABOUT SSL CERTIFICATES
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))
Dues Mark Hulett $40.00
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
VOUCH NO. WARRANT NO.
ALLOWED 20
National Association of EMT's
IN SUM OF
P.O. Box 1400
Clinton, MS 39060 -1400
$40.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1120 43- 553.00 $40.00 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
FEB 13 2nnQ
7 U
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund