215298 12/11/2012 CITY OF CARMEL, INDIANA VENDOR: 366507 Page 1 of 1
ONE CIVIC SQUARE CIRCUIT SQUARE TV-VIDEO
0 CHECK AMOUNT: $154.95
CARMEL, INDIANA 46032 9613 N.COLLEGE AVE
INDIANAPOLIS IN 46280 CHECK NUMBER: 215298
CHECK DATE: 12/11/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4350000 14459 154 . 95 EQUIPMENT REPAIRS & M
CIRCUIT.SQUARE TV-VIDEO
9613 N College Ave
Indianapolis, IN 46280
(317) 844-4000
DATE
NAME
ADDRESS 1445-9
PHONE DATE PROMISED
M� SERIA ,ONO ATE OF ORIGINAL INSTALLATION
TROUBLE REPORTED
❑ ESTIMATE ❑ CASH
` ❑ WARRANTY ❑ CHARGE
❑ CONTRACT ❑ C.O.D.
QTY. DESCRIPTION AMOUNT
,421
s
p
.Q& •tin F
I
C".
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I
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4t i In
XTI
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COMMENTS TOTAL M S /S-y
Warranty:90 days on new parts °'"'TECHNICAL
30 days labor on new pads SERVICE TIME ❑ SHOP [14%44E Q
� III ❑ R ❑ CHAR E CALL
/ nFW'd�R-� CH�eFtGE y
TECHNICIAN D llor 7 2 i
SIGNATUR / / '
TOTAL
.. Signature above constitutes acceptance of above work as being
satisfactory-and that equipment has been left in good condition.
N
•W E
S
COLOR OF HOUSE SIDE OF STREET FLOOR APT. NO.
DELIVER VIA:
DELIVERY INSTRUCTIONS:
RECEIVED BY
Before writing on this side, detach carbon,turn over and reinsert between the sheets.
Promissory Notes should be made in duplicate with one copy for customer.
PROMISSORY NOTE
$ Date
For Value Received, I,
Promise to pay to the order of
the sum of
to be paid as follows:
with interest to be paid,at the rate of
per centum per annum,from date payment is due.
L.S.
(FOR SIGNATURE OF CUSTOMER)
L.S.
(ADDITIONAL SIGNATURE IF AVAILABLE)
SIGNED AND SEALED IN THE PRESENCE OF:
(WITNESS)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
366507 Circuit Square TV-Video Terms
9613 N. College Ave.
Indianapolis, IN 46280
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
10119/12 14459 Fitness bike TV repair 29088 $ 154.95
Total $ 154.95
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.
366507 Circuit Square TV-Video Allowed 20
9613 N. College Ave.
Indianapolis, IN 46280
In Sum of$
$ 154.95
ON ACCOUNT OF APPROPRIATION FOR
109 - Monon Center
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1096-21 14459 4350000 $ 154.95 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
6-Dec 2012
Signature
$ 154.95 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund