209650 06/05/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
f ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $182.77
INDIANAPOLIS IN 46204 CHECK NUMBER: 209650
CHECK DATE: 61512012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 17965 182.77 MEDICAL EXAM FEES
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
Indianapolis, IN 46204
o Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 05/17/2012
m Invoice 00 -17965
Date Employee Description Amount Balance Due
05/07/12 Batic Zachary J. Quantiferon Tb Blood $52.28 $52.28
CMP (Comp Metabolic Panel) $20.01 $20.01
CBC Com P Blood Count 18.12 $18.12
Lipid Panel Blood 21.26 $21.26
Veni uncture $3.14 3.14
He B Titer SAb Quantitative Blood $36.59 $36.59
Iniection Fee $10.46 $10.4 6
Td Tetanus Diphtheria) Vacc $20.91 $20.91
Total Charges $182.77
Total Payments Balance Due $0.00 $182.77
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$1
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1110 I 17965 I 43- 407.01 I $182.77 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
Thursday, May 31, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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))
05/17/12 17965 officer physical $182.77
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