215080 12/04/2012 CITY OF CARMEL, INDIANA VENDOR: 00352774 Page 1 of 1
,.�.o` ONE CIVIC SQUARE JORDAN KLEINSMITH
0 CHECK AMOUNT: $22.93
CARMEL, INDIANA 46032 C/0 WASTEWATER
C/O WASTEWATER CHECK NUMBER: 215080
CHECK DATE: 12/4/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 JK 22 . 93 OTHER EXPENSES
4 Q`MI♦IRy pF!
CITY OF CARMEL Expense Report (required for all travel expenses)
NOIANP
2008 mileage reimbursement rate is 58.5 cents/mile
EMPLOYEE NAME: Jordan Kleinsmith DEPARTURE DATE: 11/14/12 TIME: AM/ PM
DEPARTMENT: Utilities/Sewer RETURN DATE: 11/14/12 TIME: AM/PM
REASON FOR TRAVEL: 76th Annual IWEA conference DESTINATION CITY: Indianapolis
EXPENSES ARE FOR (check all that apply): TRAVEL ADVANCE TRAVEL REIMBURSEMENT _X_ TRAVEL PER DIEM_
Transportation Gas/Tolls/ Meals
Date Parkin Lodging Misc. Total
Air-fare Car Rental Other g Breakfast Lunch Dinner Snacks Per Diem
11/14/12 $22.93 $22.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
j 0.00
Total 1 $0.001 $0.001 $9.001 $0.001 $0.001 $0.00 $22.93 $0.001 $0.001 $0.001 $0.00
i
DIRECTOR'S STATEMENT: I hereby affirm that all expenses listed conform to the City's travel policy and are within my department's appropriated budget. I.
Director Signature: XI/ Date:
��,Za -ice
City of Carmel Form#ER06 Revision Date 11/19/2012 Pagel
`'r"''�„ WASTEWATER OPERATOR/APPRENTICE CONTINUING To ensure proper credit,the
EDUCATION CREDIT REPORT wastewater approval number
MUST be provided.
State Form 51139(R3/4-08) Training Course Approval Number:
+� <<` INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
'elf WWT12-2767
Technical Contact Hours Earned:
Operator DApprentice 29.5
General Contact Hours Earned:
14.5
N' -�1C 10 S• <¢- r a t
In accordance with 327 [AC 5-22-17(c),the training provider must submit this form within ninety(90)days of the
conclusion of the wastewater treatment continuing education course. Mail the completed form to:
Wastewater Continuing Education Coordinator
Indiana Dept. of Environmental Management
100 N_ Senate Ave- Mail Code 65-42
Indianapolis, IN 46204-2251
- Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM.
- Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete
wastewater treatment continuing education course.
- The training provider must retain a copy of this form for their records for a three (3)year period following the
presentation of each wastewater treatment continuing education course.
- Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the
certified operator/apprentice attending the entire wastewater operator continuing education course.
C `N C I R E D OT TO P O I
1.NAME:
2.ADDRESS(number end street):
C D31 or
City:: ( l State: Z /� Telephone number:0 1 J Ho e/Cell:'18
Check here if this is an address change 0 E-mail Address:
CO RS I O IiA T10N
3.NAME OF TRAINING COURSE:
76th Annual IWEA Conference
4.NAME OF TRAINING COURSE PROVIDER: 5.NAME OF ORGANIZATION SPONSORING COURSE:
Indiana Water Environment Association Indiana Water Environment Association
6.DATE(S)ATTENDED(month,day,year): 7.LOCATION ATTENDED:
November 14-16,2012 Westin Hotel, Downtown Indianapolis-.
8.TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATOR/APPRENTICE AND VERIFIED BY INSTRUCTOR AND
TRAINING COURSE PROVIDER:
Technical Contact Hours: General Contact Hours:
• o
9.CERTIFICATE OF COMPLETION IS REQUIRED FOR ALL ON-LINE COURSES.
I,the undersigned,certify under penalty of law that this document(and any attachments)were prepared under my direction or supervision and that the
information submitted is,to the best of my knowledge and belief,true,accurate,and correct. If also understand that any omissions or misrepresentation
may result in the denial of continuing education credit for this course.
10.SIGNATURE OF INSTRUCTOR: ' 11.PRINTED NAME OF IVS C OR:
.,� SIGNATU/ E OF CERTIF ED OPl Ri4T0�2/APPRENTICE: 13.PRINTED NAME OF CERTIFIED OPERA APPRENTICE:
� r l f; J�,� �rrJa.v <� .i ♦1 off.+ r R_
k CONTINUING EDUCATION CREDIT HOURS ARE TO BE APPLIED TO:
,Jperator certification/apprentice number: Class: Expiration date:
(9- 30-/ 3
Operator certification/apprentice number: Class: Expiration date:
VOUCHER # 126228 WARRANT # ALLOWED
T9971 IN SUM OF $
KLEINSMITH, JORDAN
WASTEWATER
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
JK 01-7042-05 $22.93
Voucher Total $22.93
Cost distribution ledger classification if
claim paid under 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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T9971
KLEINSMITH, JORDAN Purchase Order No.
WASTEWATER Terms
Due Date 11/28/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/28/201', J K $22.93
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 5-11-10-1.6
Date Officer