210107 06/20/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $1,147.71
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 210107
CHECK DATE: 6/20/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 18097 472.52 MEDICAL EXAM FEES
1110 4340701 26173 18150 675.19 TESTING
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Police Department CARMEPD
Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 06!01!2012
100 Invoice 00 -18097
Date Employee Description Amount Balance Due
05/21/12 Batic, ZacharV J. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation $0.00 $0.00
Respirator/Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
Muscular Strength Endurance Test $27.18 $27.18
Flexibility Test 10.46 10.46
Body Fat Test BIA Bio -Elec Imp Anal 14.64 14.64
Waist/Hi Ratio 3.14 3.14
Treadmill Submax 159.90 159.90
Tonomet Glaucoma Test 37.64 $37.641
Vital Signs HT WT BP PR $0.00 $0.001
Vision Acuity $27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiometry $14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Total Charges $472.52
Total Payments Balance Due $0.00 $472.52
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797
Balance due 15 days from invoice
date
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
IY Indianapolis, IN 46204
C Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 06/07/2012
m Invoice 00 -18150
Date Employee Description Amount Balance Due
05/29/12 Padilla Gabrielle D. Chart Review/Completion $84.67 $84.67
Indiana PERF Exam $190.28 $190.28
Tb Skin Test $7.32 $7.32
Applicant Blood Panel PERF $120.04 $120.04
Drug Screen 7 GUMS W /MRO $41.82 $41.82
Veni uncture $3.14 $3.14
Chest X -Ray PA/LAT (Digital) 62.73 $62.73
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 27.18 $27.18
Vision Color Ishihara 27.18 $27.18
PFT Pulmonary Function T 4
Audiometry $14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 3.14
Tonomet Glaucoma Test 37.64 37.64
Total Charges $675.19
Total Payments Balance Due $0.00 $675.19
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date
Ci INDIANA RETAIL TAX EXEMPT PAGE
ty o f rme CERTIFICATE NO. 003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 973
35- 60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, A/P
CARMEL, INDIANA 46032 -2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997
'URCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
`12
Public ftfoty Modicail Bervicos Carmel Police Department
VENDOR
SHIP 3 Civic Squat
324 E. Now Yolk gtrwt, gui¢o SM TO Carmel, IN MW
Indlan2polls, IN 4M (397) 671-2M
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43-407.09
9 Each psWh phyzical for ipplicant SI�73.9:� 5 73.9
Sub Total: $575.99
ti Asa
GMAolio Pi@dllla
Send Invoice 0
Carol Police Dopadmont
Attn: Teresa Anderson
3 Civic Rqu=
Carmal, IN 46 2- PLEASE INVOICE IN DUPLICATE
DEPARTMENT 7 ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Carmel Police De pt. ��5 PAYMENT W75.99
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
SHIP REPAID.
THIS APPROPRI O UFFICIENT TO PAY.,FOR THE ABOVE ORDER.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED.
PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS. Chlof P81i��
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
CLERK TREASURER
DOCUMENT CONTROL No- 2617 A.P.V. COPY SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO. WARRANT
ALLOWED 20
IN THE SUM OF
ON ACCOUNT OF APPROPRIATION FOR
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
materials or services itemized thereon for
which charge is made were ordered and
received except_
20
Signature
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))
06/01/12 18097 officer physicals $472.52
06/07/12 18150 applicant physical $675.19
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
Public Safety Medical Services C) -3 6 0
IN SUM OF
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$1,147.71
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1110 18097 43 407.01 $472.52 I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
26173 18150 43 407.01 $675.19
materials or services itemized thereon for
which charge is made were ordered and
received except
Friday, June 15, 2012
14--� Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund