209566 06/05/2012 CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1
ONE CIVIC SQUARE HENRY SCHEIN INC
CARMEL, INDIANA 46032 DEPT CH 10241 CHECK AMOUNT: $3,605.09
a «o PALATINE IL 60055 -0241 CHECK NUMBER: 209566
CHECK DATE: 6/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 9290106 3,605.09 SPECIAL DEPT SUPPLIES
SI ORDER# I J.", DATE
05/21/12 06/20/12
WHSEDEA# RHO162494 Fed ID: 11-3136595
Z,
MRS
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MPNE ina
rhis order as been processed by our MIDWEST D.C.
5315 WES" 74TH 3TREET
INDIANAP)LIS,IN 46268
1 4ARK 317-57L-2663
1 107-0502 100/BX PURPLE NITRILE PF GLOVE MEDIUM 40 40 C 8.65 346.00 4
CASE GOOD IPEM, MAY BE SHIPPED SEPARATELY.
2 107-0530 100/BX PURPLE NITRILE PF GLOVE LARGE 40 40 C 8.65 346.00 8
CASE GOOD IPEM, MAY BE SHIPPED SEPARATELY.
3 935-6155 50/PK BLUE SENSOR SP ELECTRODES 120 120 11.55 1386.00 13
4 499-0611 20X3/ BX, ELECTRODE PEDIATRIC 4 4 9.42 37.68 17
HIS PRODUCr IS BEING SHIPPED FROM OUR NORTHEAST DISTRIBUTION CENTER.
5 116-9264 EA SEP-T SYSTEM II 12000C 48 48 C 2.98 143.04 9
CASE GOOD IrEM, MAY BE SHIPPED SEPARATELY.
6 499-6393 EA EASY GRIP BVM ADULT 24 24 C 11.25 270.00 11
CASE GOOD IPEM, MAY BE SHIPPED SEPARATELY.
7 499 EA EASY GRIP BVM CHILD 12 2 12.00 24.00 15
PARTIAL SHIDMENT WILL SHIP AND INVOICE WHEN AVAILA3LE.
8 499-6394 EA EASY GRIP BVM INFANT 12 12 12.00 144.00 15
9 420 EA NASAL ATOMIZATION DEVICE W/SYR 75 75 3.73 2 13
BILL TO SHIP TO INVOICE 4 INVOICE AMOUNT ITEM STATUS KEY FRREEMTK
1308571 1817102 9290106-01 3605.09 13- Backondcicd: Item will tollow Sel
0 0�1 �Ki
m]
DiscomiCd: Item no longer available c
HSI ORDER 11 ORDER DATE INVOICE DATE 4 OF BOXES Special Schein I Goods
M Manufacturer will ship Item directly to you
00783142 05/21/12 5/21/12 17 11 Prescription Ding: Return Authorization Required
CUSTOMER PQ4 PAGE R Refrigerated Item: May be shipped separately
Special Schein I', icing
U Temporarily unavailable: please reorder
MARK 052112 1 OF 2 T Item Continued on Next Page
9 HENRY SCHEINO
EMS Carmel TO /SOLD TO:
INVOICE Carmel Fire Department MI
135 Duryea Road, Melville, NY 11747 540 W 136 St
Station 46 Michael Kaufmann
Carmel, IN 46032 -8806
01 0000130857], 092901061 ],00],0000003605090521],23 BILL TO:
Carmel Fire Dept MI
2 Civic Sq
Carmel, IN 46032 -7543
Carmel Fire Dept
2 Civic Sq BILL TO I SHIP TO INVOICE AMOUNT
Carmel, IN 46032 -7543
1308571 1817102 1 3605.09
INVOICE# INVOICE DATE
9290106 -01 5/21/12
CUSTOMER PO
MARK 052112
19ca.co detail here and mail the uhovc'oviih your paymcm
HSI ORDER# I ORDER DATE IDUE DATE
00783142 1 05/21/12 1 06/20/12
WHSE DEA# RH0162494 Fed ID: 11-3136595
10 555 -5396 PU EA PROTECTIV ACUVNC SFT OATH 20X1.25 200 200 2.73 546.00 14
11 900 -4499 100 /BX BANDAGE SCHEIN FLEX FABRC 3/4X3" 54 54 C 1.53 82.62 12
LEASE NOTE 9004341 IS NOW 9004499
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
OUR ORDER 0783142 HAS BEEN SPLIT INTO MULTI LE SHI MENTS. CERTAIN ITEM WILL
E SHIPPED EPARATELY. YOU WILL BE BILLED FOR THESE ITEMS HEN THEY ARE HIPPED.
F YOU ARE DARTICIPATING IN A DISCOUNT PROGRA (E.G. POIN S, GIFTS OR O HER
PECIAL AWA DS "DISCOUNT WITH THIS PURCH SE YOU HAVE EARNED A CREDI TOWARD
GOODS OR S RVICES, RECEIVABLE OR REDEEMABLE N ACCORDANCE WITH DISCOUNT PROGRAM
RULES. UPO4 DISCOUNT RECEIPT OR REDEMPTION, rOU ARE RECEIIIING OR WILL R CEIVE
OTICE OF T E DISCOUNT VALUE. FROM TIME TO TI E, MEDICARE, MEDICAID, TRI ARE OR
THER PAYER MAY REQUEST INFORMATION REGARDING SUCH V LUE, P.ND UPON ANY S CH
EQUEST, SU H VALUE MUST BE DISCLOSED AS A DI COUNT GAINSq THE PURCHASES THAT
ARNED SUCH VALUE. ACCORDINGLY, YOU SHOULD RE AIN THESE RECORDS.
MERCHANDI E TOTAL 3605.09
Invoice Date 30 days 3605.09
LEASE NOTE NEW REMIT TO ADDRESS
Please remi payments only to the following a dress:
ENRY SCHEI INC`.
EPT CH 102 1
ALATINE, I 60055 -0241
BILL TO SHIP TO INVOICE# INVOICE AMOUNT
ITEM STATUS KEY REM KEY
1308571 1817102 9290106-01 3 6 0 5. 0 9 H- Backordered: Item will follow SK School I<it
D I i.scominued: Item no longer available NC No Charge
H I ORDER# ORDER DATE INVOICE DATE 4 OF BOXE
P Special Schein Free Goods
M Nlanufacmrer will ship Item directly to you
00783142 0 5/ 21 12 5/21/12 17 P- Prescription Drug: Remm Authorization Required
R RcGigerated Itcm: May be shipped separately
CUS TOMER PO# PAGE
Special Schein Pricing
U Temporarily unavailable: please reorder
MARK 052112 2 OF 2 T Taxable Item
U HENRY SCHEIN"
i
EMS SAL
Payment Terms:
We make every effor to maintain prices for the duration of a Payment by CHECK or by the HENRY SCHEIN CREDIT CARD,
catalog, however: we reserve the right to make price adjustments in VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS
response to manufacturers' price changes
vISA a
Guaranteed Satisfaction:
It you have tried a product and it is detective or does not perform or
satisfactorily, we will provide a credit, refund, or exchange; it's your dill Your Order To Your Open Account
to licensed practitioners in the U.S. All invoices are
choice. Simply call our customer service department within 30 days payable within 30 days.
of receipt of the merchandise to arrange for the return. For a
warranty repair or if you were sent something you did not order
simply call: Rx Products Controlled Substances:
Matrx Medical 1- 800-845 °3550
Regulations require us to limit the sale of Rx and controlled
substances only to registered, licensed healthcare professionals.
If you are a new customer or have recently moved, please furnish
us with a copy of your updated state registration. For controlled
substances, furnish a copy cf your DEA certificate verifying your
shipping address. Glass II drugs can be ordered only by mail.
International Orders:
Please Note:
Opened handpieces and equipment may not be returned for We proudly serve healthcare professionals and governments
credit, but will be repaired or replaced in accordance with throughout the world. To place orders or for inquiries on export
terms and conditions, please contact our International Department:
manufacturer :�varranties. Before opening handpieces or 1- 800 -815 3550
equipment, we suggest that you check the shipping container
and packing list to verify that you have received exactly ;.ghat Prescription Drug Returns Instructions:
you ordered.Opened Computer Software is not returnable.
Other restrictions may also apply.
A Return Authorization is Required for all Prescription Drugs. Simply cal{
our Customer Service Department 1- 800 -845 -3550.
LP300
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))
9290106 $3,605.09
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.
ALLOWED 20
Henry Schein
IN SUM OF
Dept Ch 10241
Palatine, IL 60055
$3,605.09
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. I ACCT #/TITLE AMOUNT Board Members
1120 I 9290106 1 102- 390.11 I $3,605.09 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
JUN 4 2012
xi"
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund