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Home My WebLink About216848 01/29/2013 CITY OF CARMEL, INDIANA VENDOR: 358681 Page 1 of 1 ONE CIVIC SQUARE PURDUE UNIVERSITY PEC BUS OFFICE CHECK AMOUNT: $40.00 ;'. CARMEL, INDIANA 46032 128 MEMORIAL MALL + .a� STEWART CENTER ROOM 110 CHECK NUMBER: 216848 WEST LAFAYETTE KS 47907-2034 CHECK DATE: 1/29/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4357004 PARKING 40 . 00 EXTERNAL INSTRUCT FEE REGISTRATION FORM . 9 Purdue Road School Purdue University- March 5-7,2013 Register ®n-lire at:www.conf.purdue.edu/RoadSchool PURDUE RO Pre-registration will close on Feb.28,2013. After that attendees will need to register on-site. CHOOL Confirmation of registration will be emailed to the address provided. CONTACT INFORMATION- Please type or print separate forms for each person from your organization. AFFILIATION ( _06CI City/Town First name Middle Initial Last Nanie ❑ County T Name to appear on badge if different than above ❑❑ INDO INDO Title a C\V�(I I Y_ ❑ PurdueUniversity Faculty/Staff �t 1 ❑ Purdue University Student Company/Organization C 1 1 V op 0�"( ❑ MPO 1 Address Line I ,-1V1 o. &-,, tw e. ❑ Non-Government n � Purdue is committed to making its City l fl.(�1/lll State/Province �N Zip/Postal Code �� Z programs accessible to individuals with 11 disabilities.If you require an Phone *Email Address Q Poke Ll 9cQYMA, accommodation or special assistance for Email address is required in order to send confirmations and other important communication. this program due to a disability,please contact us at 866-515-0023. REGISTRATION FEE INFORMATION PAYMENT INFORMATION ❑Non-Government $75.00 ❑Enclosed is a check payable to Purdue University ❑Government Complimentary ❑Please charge my credit card: Any ,local agency,state and federal personnel qualifies for the complimentary rate. ❑MasterCard ❑Visa [I Discover ❑American Express Optional Fees: Account Number: ❑1 would like to attend the luncheon on Wednesday,March 7 $20.00 ❑1 am requesting a vegetarian meal. Expiration Date: ❑1 plan to attend the Tuesday evening Welcome Reception at the Four Points by Sheraton-West Lafayette. Signature: ❑1 would like to have a transcript of the PDH/CEU Printed Name: recorded by Purdue at this conference $6.00 Parking(For Tuesday and Wednesday-'A'Permit) $10.00 Enclose payment and return to: CONFERENCE DIVISION February25 is the last day to order permits. Purdue University They will be mailed on February28. Total Due: 10-O0 Stewart Center,Room 116 , By registering for this event,I understand that at this event,or related activities,I may be 128 Memorial Mall photographed.I agree to allow photo,video or film likeness to be used for any' West Lafayette,IN 47907-2034 legitimate purpose by the event holders,producers,sponsors and/or organizers FAX with credit card information to: 765-494-0567 without compensation or notice to me. Signed REGISTRATION DEADLINES Pre-registration for Road School will be available from January 15 through February 28,2013.No faxes will be accepted after 5pm EST on February 28,2013. Confirmations will be emailed to those who register on or before February 28,2013. If you miss the pre-registration window and would still like to attend Road School,On-site registration will be available beginning at 7am in the exhibitor hall. REGISTRATION FEES Pre-registration On-Site registration January 15-February 28,2013 March 5-6,2013 Government Agencies Free Free (Local,State,Federal) Private Sector $75.00 $100.00 0 0 vvth Annual Purdue Road School Pardue University - March 5-7,2013 Register on-line at:www.conf.purdue.edu/RoadSchool PURDUE RO Pre-registration will close on Feb.28,2013. After that attendees will need to register on-site. CHOOL Confirmation of registration will be emailed to the address provided. CONTACT INFORMATION- Please type or print separate forms for each person from your organization. AFFILIATION lzY City/Town First name Middle Initial Last Name ❑ County T Name to appear on badge if different than above ❑❑ INDO INDO Title 0'1-AN =0Q a\PP C ❑ Purdue"University Faculty/Staff 1 Company/Organization Y ❑ Purdue University Student ❑ MPO r Address Line 1 : C�1�C' ❑ Non-Government Purdue is committed to making its City 0(_0/00 State/Province Zip/Postal Code 4(o0-9_2_ programs accessible to individuals with ^ disabilities.If you require an Phone'al-24' 1 I *Email Address MY1(l _V_yl ,SxYmel- n- Qf accommodation or special assistance for Email address is required in order to send confirmations and other important communication. this program due to a disability,please contact us at 866-515-0023. REGISTRATION FEE INFORMATION PAYMENT INFORMATION ❑Non-Government $75.00 ❑Enclosed is a check payable to Purdue University ❑Government Complimentary ❑Please charge my credit card: Anylocal agency,state and federal personnel ❑MasterCard ❑Visa ❑Discover ❑American Express qualifies for the complimentary rate. Optional Fees: Account Number: ❑1 would like to attend the luncheon on Wednesday,March 7 $20.00 ❑1 am requesting a vegetarian meal. Expiration Date: ❑1 plan to attend the Tuesday evening Welcome Reception at the Four Points by Sheraton-West Lafayette. Signature: ❑1 would like to have a transcript of the PDH/CEU Printed Name: recorded by Purdue at this conference $6.00 ❑Parking(For Tuesday and Wednesday-'A'Permit) $10.00 Enclose payment and return to: CONFERENCE DIVISION February 25 is the last day to order permits. Purdue University They will be mailed on February 28. Total Due: Stewart Center,Room 116 By registering for this event,I understand that at this event,or related activities,I may be 128 Memorial Mall photographed.I agree to allow photo,video or film likeness to be used forany' West Lafayette,IN 47907-2034 legitimate purpose by the event holders,producers,sponsors and/or organizers FAX with credit card information to: 765-494-0567 without compensation or notice to me. Signed REGISTRATION DEADLINES Pre-registration for Road School will be available from January 15 through February 28,2013.No faxes will be accepted after 5pm EST on February 28,2013. Confirmations will be emailed to those who register on or before February 28,2013. If you miss the pre-registration window and would still like to attend Road School,On-site registration will be available beginning at 7am in the exhibitor hall. REGISTRATION FEES Pre-registration On-Site registration January 15-February 28,2013 March 5-6,2013 Government Agencies Free Free (Local,State,Federal) Private Sector $75.00 $100.00 ® s Annual Purdue Road School Purdue University- March 5-7,2013 Register on-line at:www.conf.purdue.edu/RoadSchool PURDUE RO Pre-registration will close on Feb.28,2013. After that attendees will need to register on-site. CH00L Confirmation of registration will be emailed to the address provided. CONTACT INFORMATION- Please type or print separate forms for each person from your organization. AFFILIATION &'v"I 7 c1 __:U) woo-A- k City/Town First riame Middle Initial Last Name ❑ County ❑ INDOT Name to appear on badge if different than above ❑ FHWA Title ❑ Purdue University Faculty/Staff Company/Organization-11(� �I[' av ❑ Purdue University Student ❑ MPO Address Line t n / Q ❑ Non-Government 1 Purdue is committed to making its City l �Y n&l �L . State/Province Zip/Postal Code �lp C7�2- programs accessible to individuals with �� //� disabilities.If you require an Phone \�— S34- 2+1 *Email Address Q Ci.u�\nCav��0,0.v'YVId , IY\,Q 6\ accommodation or special assistance for Email address is required in order to send confirmations and othe�ra ortant communication. this program due to a disability,please contact us at 866-515-0023. REGISTRATION FEE INFORMATION PAYMENT INFORMATION ❑Non-Government $75.00 ❑Enclosed is a check payable to Purdue University ❑Government Complimentary ❑Please charge my credit card: Any ,local agency,state and federal personnel ❑MasterCard ❑Visa ❑Discover ❑American Express qualifies for the complimentary rate. Optional Fees: Account Number: ❑1 would like to attend the luncheon on Wednesday,March 7 $20.00 ❑1 am requesting a vegetarian meal. Expiration Date: ❑1 plan to attend the Tuesday evening Welcome Reception at the Four Points by Sheraton-West Lafayette. Signature: ❑1 would like to have a transcript of the PDH/CEU Printed Name: recorded by Purdue at this conference $6.00 [Parking(For Tuesday and Wednesday-'A'Permit) $10.00 Enclose payment and return to: CONFERENCE DIVISION February 25 is the Iasi day to order permits. They will be mailed on February 28. Purdue University Total Due: (0.o0 Stewart Center,Room 116 By registering for this event,I understand that at this event,or related activities,I maybe 128 Memorial Mall photographed.I agree to allow photo,video or film likeness to be used for any, West Lafayette,IN 47907-2034 legitimate purpose by the event holders,producers,sponsors and/or organizers FAX with credit card information to: 765-494-0567 without compensation or notice to me. Signed REGISTRATION DEADLINES Pre-registration for Road School will be available from January 15 through February 28,2013.No faxes will be accepted after 5pm EST on February 28,2013. Confirmations will be emailed to those who register on or before February 28,2013. If you miss the pre-registration window and would still like to attend Road School,On-site registration will be available beginning at 7am in the exhibitor hall. REGISTRATION FEES Pre-registration On-Site registration January 15-February 28,2013 March 5-6,2013 Government Agencies Free Free (Local,State,Federal) Private Sector $75.00 $100.00 0 0 Annual Purdue OR'bad School Purdue University- March 5-7,2013 PUR Register on-line.at:www.conf.purdue.edu/RoadSchool ....1 TE RO Pre-registration will close on Feb.28,2013. After that attendees will need to register on-site. CHOOL Confirmation of registration will be emailed to the address provided. CONTACT INFORMATION- Please type or print separate forms for each person from your organization. AFFILIATION PAM 7 �17V��/L= S M City/Town First name Middle Initial Last Name ❑ County ❑ INDOT Name to appear on badge if different than above Title CON&KAJ DL�IU y ° "O /M� EnAh -!S 7� �J� ❑ Purdue University Faculty/Staff Company/Organization C(� OF CA(V`�'C - ❑ Purdue University Student qn ❑ MPO Address Line 1 0100 C,01 C Set)I)Ae _ ❑ Non-Government , f z Purdue is committed to making its City L—+"t +�6 - State/Province A Zip/Postal Code �✓ programs accessible to individuals with 2 7 (�n n,n disabilities.If you require an Phone 3�7-S!/- Z5(o "( *Email Address D 1 t4gy', � @ C-AA% t-1 r 711)' y 0 y accommodation or special assistance for Email address is required in order to send confirmations and other important communication. this program due to a disability,please contact us at 866-515-0023. REGISTRATION FEE INFORMATION PAYMENT INFORMATION ❑Non-Government $75.00 ❑Enclosed is a check payable to Purdue University Qld�olernment Complimentary ❑Please charge my credit card Any local agency,state and federal personnel ❑MasterCard ❑Visa ❑Discover ❑American Express qualifies for the complimentary rate. Optional Fees: Account Number: ❑1 would like to attend the luncheon on Wednesday,March 7 $20.00 ❑1 am requesting a vegetarian meal. Expiration Date: ❑1 plan to attend the Tuesday evening Welcome Reception at the Four Points by Sheraton-West Lafayette. Signature: /0'I ould like to have a transcript of the PDH/CEU Printed Name: orded by Purdue at this conference $6.00 rking(For Tuesday and Wednesday-'A'Permit) $10.00 Enclose payment and return to: CONFERENCE DIVISION February25 is the last day to order permits. They will be mailed on February 28. Purdue University Total Due: Stewart Center,Room 116 By registering forthis event,I understand that at this event,or related activities,I may be 128 Memorial Mall photographed.I agree to allow photo,video or film likeness to be used for any West Lafayette,IN 47907-2034 legitimate purpose by the event holders,producers,sponsors and/or organizers FAX with credit card information to: 765-494-0567 without compensation or notice to me. Signed REGISTRATION DEADLINES Pre-registration for Road School will be available from January 15 through February 28,2013.No faxes will be accepted after 5pm EST on February 28,2013. Confirmations will be emailed to those who register on or before February 28,2013. If you miss the pre-registration window and would still like to attend Road School,On-site registration will be available beginning at lam in the exhibitor hall. REGISTRATION FEES Pre-registration On-Site registration January 15-February 28,2013 March 5-6,2013 Government Agencies Free Free (Local,State,Federal) Private Sector $75.00 $100.00 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 Purdue University; Stewart Center RM 116 Purchase Order No. 128 Memorial Mall Terms West Lafayette, IN 47907-2034 Date Due Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s) Amount 1/0/1900 0 Road School Parking (4) $ 40.00 Total $ 40.00 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 NC WARRANT NO. Purdue University; Stewart Center RM 116 ALLOWED 20 128 Memorial Mall IN SUM OF $ West Lafayette, IN 47907-2034 $ 40.00 ON ACCOUNT OF APPROPRIATION FOR Board Members Po#or INVOICE NO. ACCT#/TITL AMOUNT DEPT# I hereby certify that the attached invoice(s), 0 0 2200-4357004 $ 4000 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 1/28/2013 Signature City Engineer Cost Distribution ledger classification if Title claim paid motor vehicle highway fund