180888 12/30/2009 CITY OF CARMEL, INDIANA VENDOR: 204038 Page 1 of 1
ONE CIVIC SQUARE MIDWEST TOXICOLOGY SVS,INC
CARMEL, INDIANA 46032 603 E WASHINGTON ST SUITE 200 CHECK AMOUNT: $55.00
INDIANAPOLIS IN 46204 CHECK NUMBER: 180888
CHECK DATE: 12/3012009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1201 4358800 19348 194421 55.00 TESTING FEES
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Midwest Two cofogy Invoice
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DATE INVOICE
12/9/2009 194421
603 East Washington Street, Suite 200, Indianapolis, IN 46204
BILL TO: SHIP TO:
City of Carmel Names location of collection
Attn: Jim Spelbring on invoices no ss#
1 Civic Square Email results to Barb Lamb cc Jim
Carmel, IN 46032 Still Mail results to Jim
CLZ
CONTROL P.O. NUMBER JOB SITE TERMS FACILITY
5528 Due on receipt 142376
ITEM CODE QTY DESCRIPTION PRICE EACH AMOUNT
ND Drug Test 1 Non -DOT Drug Test 55.00 55.00
Collected at Community Occupational Health Center- Carmel
12/07/09
Richard Lovitt
A finance charge will be assessed on all invoices not paid in 30 days. Thank you for your business.
For the purpose of client confidentiality we are no longer showing the full SSN on invoices. Total $55.00
Make Checks Payable To: MIDWEST TOXICOLOGY SERVICES, INC.
For questions regarding this invoice, contact us at 317- 262 -2200 or fax us at 317- 262 -2222.
Be sure to visit our website at rvrvw.n:idwesttoxicology.cornr.
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Midwest Toxicology
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/09/09 194421 Non -DOT Drug Test
Total $55.00
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
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ALLOWED 20
Midwest Toxicology
IN SUM OF
603 E. Washington St, Suite 200
Indianapolis, IN 46240
$55.00
ON ACCOUNT OF APPROPRIATION FOR
General Fund
1205 Human Resources
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
19348 194421 588 $55.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
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Cost distribution ledger classification if Title
claim paid motor vehicle highway fund