172952 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 219001 Page 1 of 1
I: ONE CIVIC SQUARE NATIONAL FIRE PROTECTION ASSOC CHECK AMOUNT: $295.00
CARMEL, INDIANA 46032 C/O EXGENEX INC
w, 437 FURNPIKE STREET CHECK NUMBER: 172952
CANTON MA 02021
CHECK DATE: 5/27/2009
DEP ARTME NT ACCOUNT PO NUMBER IN VOICE NUMBER AMOUN DESCRIPTION
1120 4357004 295.00 EXTERNAL INSTRUCT FEE
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STEP 1: GENERAL INFORMATION
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First Name: Ch r i S t Last Name: I r'• h r
fide: 6 2 p f� F M y r S k a) 0 PE 0 PhD O CFPS 0 Other r r I r r r r
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Company /Affiliation: L a P m C. 1 F; I e p{
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Mailing Address: u
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City e z✓ r E L State /Zip /Country: >\J Cis Z NFPA is committed to providing appropriate accommodations for persons with
disabilities so that everyone may have access to our programs and events.
Email (required): C F s a n) Q C a P M 1 v Q V First -Time Attendee O Please check here if you would like NFPA to contact you regarding appropri-
ate accommodations, or contact us at 617-984-73 10.
Daytime Phone: I Z CEO Fax: 3 1 S 7 I Z(�� y
Spouse Name for Badge (ifatttending):. Admissiontogeremismionandexpoonly) STEP 4• PAYMENT INFORMATION
Emergency Contact Name: /3 G N Cf h_ I I s o �J Emergency Contact Phone: 3 I S y FULL PAYMENT IS DUE WITH REGISTRATION. PURCHASE ORDERS NOT
Emergency Contact Email: n C/ t1 I G O e,. ACCEPTED. NFPA WILL NOT INVOICE FOR CONFERENCE OR SEMINARS.
J p e (YL l/Gt s y
Enclosed is my check b payable to Al
MEMBERSHIP INFORMATION isnol name must appear on check.)
O NFPA Member q '2.6 I I 10 1 O Non Member Charge to the following credit card:
O Technical Committee Member (Committee name) O r'M7 O W O ISM O
STEP 2: CONFERENCE REGISTRATION r Card I:
FULL CONFERENCE REGISTRATION Includes all sessions and the Exposition (does not include Pre Conference Seminars)
EARLY -BIRD RATE (by April 30, 2009) REGULAR RATE (after April 30, 2009) AMOUNT Expiration Date:
O NFPA Member $695 O Non Member $795 O NFPA Member $795 O Non Member $895 Name on Card:
OTCMFPA Member $550 0TCINon- Member$635 OTCINFPA Member $635 OTCINon- Member$715 S
Signature:
SINGLE REGISTRATION Includes Exposition; does not include Pre- Conference Seminars (Choose one day only)
O Mon es O Wed/lhur FPA Member $265 Non Member $295 Billing Address (ifdifferent):
OTCINFPA Member 03OTCLNon- Member$235 $c�°�S"
0 EXPOSITION 011 Does not include Conference of Pre- Conference Seminars O Member O Non- Member FREE
Free when you register in advance. $95 Onshe (unless you present this form) STEPS: ATTENDEE INFORMATION
STEP 3: PRECONFERENCE SEMINAR (JUNE 68)REGISTRATION
Which ofthefollowing best describes yourcurrentiob function (Checkone only)
O A. Architect O K. Inspector /Building Official
Pre- Registration required (does not include Conference)
O B. Building Owner /Manager O L Installer
I am registering for the fallowing Pre- Conference Seminar(s)... O WITHOUT the Exposition O WITH the FREE Exposition O C. Consultant /Consulting Engineer O M. Loss ControURiskManager
Automatic Sprinkler (Sat /Sun /Mon) O Member $895 O Non Member $995 O D. Contractor O N. Manager /Administrator
Fire Alarm Code° (Sat /Sun /Mon) O Member $895 O Non Member $995 O E Educator O 0. Manufacturer
O E Engineer O P. Owner /Nesident/CEO
Life Safety Code' Essentials (Sat /Sun /Mon) O Member $895 O Non Member $995 S O G. Facilities Manager O 0. Safety/Security Manager
CFPS Primer (Sat /sun) 0 Member $625 /O Non-Member $695 O H. Fire Chief O R. Sales /Marketing
Code Req' s for Maintaining Fire Life Safety O I. Fire Marshal O S. Other
Systems(SatlSun) OMemberS625 /O Non Member $695 mil. HreService
Environment of Care: The Next Evolution... (Sal/Sun) O Member $625 O Non Member $695 What industry or business is your organization in? (Check all that apply)
Life Safety Code °Plans Review(Sat/Sun) 0 Member $625 /O Non-Member $695 O A. Architecture O I. Health Care
NFPA 1, Fire Code (Sat/Sun) O Member $625 O Non Member $695 O B. Contractor /Installation O 1. Industry/Factory /warehouse
NFPA 45, Fire Safety in Research Labs (Sal/Sun) O Member $625 O Non Member $695 S O C. Commercial (Office, Retail, Restaurant) O K. Insurance /Risk Management
O D. DetentionlPrisons O L Lodging
NFPA 70E" Electrical Safety in the Workplace* (SadSun) O Member $625 ONon Member $695 O E. Education O M. Military
NFPA 921, Fire Explosion Investigations (Sat /Sun) O Member $625 O Non Member $695 O E Electrical Services O N. Utilities
NFPA 1600, Disaster/Emery. Mgmt Bus Continuity Prgms. (SadSun) O Member $625 O Non Member $695 G. he Service (public or private) EMS O 0. Other
H. Government
Crowd Safety and the Life Safety Col (Sat) O Member $345 O Non Member $395 Which of the following products do you buy, specify, recommend, or
Explosion Prevention and Protection (Sat) O Member $345 O Non Member $395 approve for your company? (Check all that apply)
IAE /Soares Grounding Bonding (Sat) O Member $345 O Non Member $395 A. Alarm /Detection Systems O G. Hazmat Storage /Handling
NFPA 13 Proposed Changes (Sat) O Member $345 O Non Member $395 R Building Construction Materials H. Pumps/ControlsNalves
Sprinkler Systems Plans Review (Sat) O Member $345 O Non- Member $395 O C. Educafion/lraining O I. Security Products /Services
O D. Electrical Equipment/Services 3K 1. Sprinklers /Sprinkler Systems
Dust Explosion Hazards (Sun) O Member $345 ONon Member $395 O E Extinguishers /Foams /Exiting Equip. O K. Signaling Systems
Emergency Evacuation for People with Disabilities (Sun) O Member $345 O Non- Member $395 S X F. Fire Department Equip. /Services O L Other
Ill 72°— Proposed Changes (Sun) O Member $345 O Non Member $395 How much fire protection/life safety equipment/services does your
NFPA 99, Health Care Facilities (Sun) O Member $345 ONon Member $395 company buy or specify annually? (Check one only)
Behind- the Scenes Tour— Fermi National Labs (Sat) 0 Member $195 /O Non- Member $225 O A. Less than $150,000 O D. $1,000,000to$S,000,000
O B. $150,000 to $500,000 E. More than $5,000,000
Behind the Scenes Tour UL Facility (Sat) O Member $195 O Non Member $225 O C $500,000 to $1,000,000 E Not Applicable
TOTAL REGISTRATION AMOUNT S Purchasing Authority? (Check one only)
O A. Recommend O B. Specify ,;!i§ C. Approve O D. Nolnvolvement
Photo identification is required to pick up your registration materials onsite. You may not pick up anyone else's materials. One -day registrations can only be picked up on the day the registration is valid. CANCELLATION POLICY.°
Written cancellation requests must be submitted on or before May 16, 2009, to qualify for a refund. Refunds will reflect a $75 processing fee. After May 16, 2009, no refunds will be issued. Cancellations must be sent to:
NFPA Registration, c/o Exgenex, lnc.r 4371urnpike Street, Canton, MA 02021; phone 888- 397 -6209; email NFPA2009 @exgenex.com
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
r'
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 Ellison $295.00
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 N WARRANT NO.
ALLOWED 20
NFFA Registration
C40 of Engenex, Inc. IN SUM OF
437 Turnpike Street
Canton, MA 02021
$295.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1120 43- 570.04 $295.00 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
MAY 2 2 2009
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund