211805 08/14/2012 CITY OF CARMEL, INDIANA VENDOR: 362435 Page 1 of 1
0 ONE CIVIC SQUARE INDIANA SECTION AWWA CHECK AMOUNT: $350.00
CARMEL, INDIANA 46032 PO BOX 534
ATTN: ALAN WISEMAN CHECK NUMBER: 211805
NASHVILLE IN 47448
CHECK DATE: 8/14/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 5795-C 350 . 00 EMPLOYEE PEN & BENEFI
Invoice
Indiana Section, AWWA
Date Invoice#
PO Box 534
Nashville, IN 47448 8/7/2012 5795
TELEPHONE: 866-213-2796 Terms
FAX: 866-215-5966
Due on receipt
Bill To
City of Carmel
3450 W. 131 st St.
Carmel, IN. 46074
V` P.O. No.
Description Amount
Indiana Section Operator School 2012 - Indianapolis - J Rayle 350.00
8/7/2012 E-mail to kloveall @carmel.in.gov
CREDIT CARD:Visa MC Discover American Express
# Exp.: -
NAME ON CARD: Security:
SIGNATURE _Billing Zip Code:
Total $350.00
PUBLIC WATER SUPPLY APPLICATION FOR . ..FOR OFFICE
°� WS number:
WATER TREATMENT PLANT AND WATER
s; DISTRIBUTION SYSTEM OPERATOR
� Receipt number:
CERTIFICATION
State Form 12094 (R6 12-06)
Approved by State Board of Accounts 2006 Approved:
327 IAC 8-12-1
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
DRINKING WATER BRANCH Denied/Reason:
NOTE: A$30 fee must be submitted with each application for certification. Applications must
be signed by the individual,and his/her supervisor. Failure to file a properly completed
application may result in the application being disapproved. (THE APPLICATION FEE
IS NONREFUNDABLE)
This is an application for Grade:(check one-One application per grade checked):
Water Distribution System ❑ ❑ 11 PWS ID#: ZZ 00
Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION
Water Treatment Plant Operator El, , 2 ® 3 4 5 06 [0]1. El Northwest CK Central
❑
❑Northeast Southwest
Southeast
9 By examination ❑By reciprocity
1. Name of applicant(last) (first) (middle)
®Mr. ❑Mrs. []Ms. —SAU
2. Mailing address(number and street): •]
231090 Duds e- QD. 7
City: State: ZIP code: County:
AuAwA 1+.1. LI(o030
3. O ice telephone number: 4. Ho a telephone number:
317 57 I- Z WA 311 (ao1 -S4-11)
5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?)
❑Yes' INNo 'If yes,date(mm/dd/yyyy):
6. Are you presently a certified water works operator in Indiana?
❑Yes' ®No 'If yes,give certification number and classification:
7. Are you presently a certified water works operator in another slate?
[]Yes* ®No 'If yes,give certification number and classification(attach a copy of certificate)
8. Have you ever had a certification suspended or revoked?
❑Yes XNo
9. Social Security number:'
31 O _ Q yn_ 'q 'Your Social Security number is being requested by this state agency in order to expedite
O processing of your application. Disclosure is voluntary and you will not be penalized for refusal.
• • •• • • •-
10. Check the highest grade completed.
Grade School: High School: College(years):
❑1 02❑3❑4❑5❑6❑7❑8 09❑10 Ell 912 ❑1 02❑3❑4❑5❑6❑More than 6 years
11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': W�.SIFIEI
MYes ❑No ❑GED OS , - 1p190 \41ESTPIE11-D H16NSCHDOL I�•
12. College Graduate? Degree: Major:
❑Yes [$No
Date granted(mm/dd/yyyy): Name and location of college:
(Continued on page 2)
Proof of education must be submitted when used as a substitution for experience.
Page 1 of 3
13. Training courses,short courses,or other courses attended applicable to water industry:
a. Name of course:
Name of school: Dates: College units or class hours:
b. Name of course:
Name of school: Dates: College units or class hours:
► List your current assignment first. Show all experience in the Drinking Water field. Attach additional sheets,if necessary.
DATE POSITION TITLE
(Month and Year) AND EMPLOYER NAME/ADDRESS
JOB DUTIES
FROM: TO: Position title: Name of current employer:
2o 1a, I 1MAMIN 0.1.7.
CAEM6L. WR7GQ. UTILITIES
Specific duties performed in day-to-day operation: Address:(number and street)
�AC_Y_\,1'15}F 12.01.1 F�IL_T�,S, SoF7��S. 34 SO `�•l.131 sT.
NIL-1 l'e0�- ME>A_T VACILrnl , LABS
City,state,ZIP code:(
(;e,7% -me- SArn�J F—� -rm—riW JES?Fi b
11j. LK7!f
A1W&j Q'Xe AND REIQS an! _TQURT M EST FAc1 u-111
FROM: TO: Position title: Name of previous employer:
I 14 )Z008 srm&rrio4 LA&e- NertrlEL WATM OTILITIE5
Specific duties performed in day-to-day operation: Address:(number and street)
'j?sPAQS 70 WP,rM ft1AW S,SEQ.I IC-E UaES. PWZ HJUArns, 34SO N4 1311 :T-
I Pi ve 5. l
ImS7A 7I� �� �� mA1NS� SIEQJ ICF 3&5, r'e-F- City,state,ZIP code:
V4LdES, r+t1e-mkS. 1n/cs-rFiesL_f_) )1J, HW_114
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-to-day operation: Address:(number and street)
City,state,ZIP code:
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-to-day operation: Address:(number and street)
City,state,ZIP code:
(Continued on page 3)
Page 2 of 3
A&VAL02:3 . _ .-
I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge.
I have supervised this individual for A 13 years.
Name of Certified Operator under whose supervision experience obtained Certification Number(s):
,7 A ,e-I /ova w-Tcig7D 19
Signat re of Certified Operator 05 O a q
Printed name and signature of applicant's supervisor:(if different than above) Applicant's supervisor:(if different than above)
Name of organization/utility/system: Telephone number:(include area code)
G i - ,eft �e_ ( 3 i - 73 - 8
Address:(number and street)
I L4 a tom• l r►
City: State: ZIP code:
I,the undersigned,certify that I am the above applicant;that all statements made and information contained in the above application are true and correct to
the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for,or
revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied.
0810, 1 Zo,z
Sign ure of applicant: Date(mmlddlyyyy):
The completed application,along with all required fees and attachments should be mailed to:
Indiana Department of Environmental Management
Cashier's Office,Mail Code 50-10C
100 North Senate Avenue
Indianapolis,IN 46204-2251
Please make all checks payable to the Indiana Department of Environmental Management
(3240-4114-00-140000)
DO NOT SEND CASH.
Page 3 of 3
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
351668
AWWA-IN SECTION-OPERATOR TRAIN Purchase Order No.
P.O. BOX 534 Terms
NASHVILLE, IN 47448 Due Date 8/9/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/9/2012 5795-C $350.00
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 5-11-110-1.6
Date Officer
VOUCHER # 121822 WARRANT # ALLOWED
351668 IN SUM OF $
AWWA-IN SECTION-OPERATOR TRAII
P.O. BOX 534
NASHVILLE, IN 47448
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO # INV# ACCT# AMOUNT Audit Trail Code
5795-C 01-6040-03 $350.00
Voucher Total $350.00
Cost distribution ledger classification if
claim paid under vehicle highway fund