HomeMy WebLinkAbout218594 03/25/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $720.00
INDIANAPOLIS IN 46204
CHECK NUMBER: 218594
CHECK DATE: 3/2512013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 19927 508 . 09 MEDICAL EXAM FEES
1110 R4340701 25572 19927 211 . 91 PHYSICALS
INVOICE
o Public Safety Medical Services
= 324 E. New York Street
E Suite 300
w Indianapolis, IN 46204
C Carmel Police Department/CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 03113/2013
m Invoice# 00-19927
Date Employee Description Amount Balance Due
03/05/13 Gauthier Edward B. PSY-Specialty Unit Psych SWAT 360.00 $360.001
03/06/13 1 Barlow Cody J. PSY-Si)ecialtv Unit Psych SWAT $360.00 $360.001
Total Charges-> $720.00
Total Payments&Balance Due-> $0.00 $720.00
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 date
INDIANA RETAIL TAX EXEMPT PAGE
City o Carmel CERTIFICATE NO.003120155 002 0 li PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 72
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
PURCHASE ORDER DATE DATE REQUIRED REQUISITION: t VENDOR NO. DESCRIPTION
71`131. 92
Public Wet y Medical Setvices Carmel Police Department
VENDOR .. SHIP 3 Civic Square
324 E. Now Fork Street, Suite 300 TO Carmel, IN 46032
Indianapolis, IN 40204 (317)571 M
CONFIRMATION BLANKET CONTRACT PAYMENTTERMS _ FREIGHT
QUANTITY
A�y UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43.405g.0 8
1 Each plysir,21 to applicant $3,500.00 $3,500.00
1 Each Otf@er Physicals $3.500.00 $3,500.00
ub Total: $7,00 A.Ob
L4
Send Invoice :
Carmel Police Department
Attn: Teresa Anderson
3 Civic Square
Cam@l, IN dam- PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT 7 PROJECT ACCOUNT AMOUNT
Cartel Police Dept. PAYMENT $7,000.00
• 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 CERTI FY THAT THERE IS AN UNOBLIGATED BALANCE IN
SHIP REPAID. THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
•
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED. {
ORDERED BY �r
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL A�
SHIPPING LABELS. `j/Chlof et Police
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. V
0 (?�
CLERK-TREASURER
DOCUMENT CONTROL NO. A.P. . COPY-SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO. WARRANT NO..__...._._�.
ALLOWED 20
IN THE SUM OF n
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
20
.....................--.........._............................................
_ Signature
.......................................................................................................................................
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$720.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 19927 43-407.01 $508.09 I hereby certify that the attached invoice(s), or
Encumbered bill(s) is (are) true and correct and that the
25572 19927 43-407.01 $211.91
materials or services itemized thereon for
which charge is made were ordered and
received except
Wednesday, March 20, 2013
Chief of Police
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))
03/13/13 19927 SWAT evaluations-C. Barlow/Gauthier $508.09
03/13/13 19927 officer physicals $211.91
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