219153 04/18/2013 "yF CITY OF CARMEL, INDIANA VENDOR: 367063 Page 1 of 1
ONE CIVIC SQUARE GEORGIA F.O.G.ALLIANCE
t,o CARMEL, INDIANA 46032 Po sox a CHECK AMOUNT: $190.00
ATTN:TREASURER CHECK NUMBER: 219153
GRIFFIN GA 30224
CHECK DATE: 4/18/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 190 . 00 TRAINING
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GEORGIA F.O.G CONFRENCE AND INSPECTOR TRAINING COURSE REGISTRA... Page 1 of 2
GEORGIA F.O.G CONFRE NCE AND INSPECTOR TRAINING
COURSE REGISTRATION FOR
April 23rd thru 25th, 2013
Merle Manders Conference Center- Stockbridge, Georgia 30281
Thank you for registering to attend the 4th Biannual Georgia F.O.G Conference and Inspector Training Course.We want to make
the process as easy as possible.New for this year is the ability to pay for your registration online. You will need to complete a
separate registration form for each individual attending this event and submit in individually.
If you have any questions about registration,please call 678-233-4353.
Registration Information:
First Name'
Last Name' Lewis _
LGA or Municipality or Company Name: City of Carmel,Indiana
Position:' Manager/Supervisor — _
Street Address' 760 Third Ave.S.W.Ste#110
Address Line 2
City Carmel
State'
Postal Code/Zip Code' 46032
Communication Information:
Cell Number' 317-716-5910
Fax Number 317-571-2265
Phone Number' 317-571-2477
E-mail* Uewis @carmel.in.gov v
Web-site: carmel.in.gov
Conference TShirt Color:' Navy 0 Burgundy
Conference TShirt Size:' `Adult_L
Special Class Registration:
Confined Space Entry Class: This class is a 6 Hour class on Confined Space Entry. This class has an extra cost because it requires a certified instructor
and also gives you your certification in Confined Space Entry.
Please sign me up for the Confined Space Entry Class. I understand that this class is an extra fee class to the conference.
There is a minimum of 25 people to have a full class. This Gass will be taught on April 23rd,2012.
Confined Space Entry $95.00(Must be added to your registration fee)
Conference Fees:
Registration Fees Non-Member:
Early Registration Rate (Paid by 03-15-13) rl $240.00 (Must be paid by 03-15-13)
Registration Rate(Paid after 03-15-13) o) $265.00 (Fee paid after 3.15-13)
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Registration Fees Members:
Early Registration Rate(Paid by 03-15-13) i $190.00 (Must be paid by 03-15-13) �
Registration Rate(Paid after 03-15-13) rl $215.00 (Fee paid after 3-15-13)
My current membership number is: –
(Membership number is located on the website)
-----------------------------------------------------------------------------------------------------------------------------------------
I wish to be a member of the Georgia F.O.G Alliance and my yearly membership fee is included with my class enrollment.
https://adobeformscentral.cony/?f=OGDPmUkRLIf6P3,nDBglzyQ 4/12/2013
GEORGIA F.O.G CONFRENCE AND INSPECTOR TRAINING COURSE REGISTRA... Page 2 of 2
Georgia FOG Alliance Yearly Membership Fee ^ $26.00 Individual Membership Fee for 2013 Year
$26.00 Associate Membership Fee for 2013 Year
Badge Information:
Name on Badge:* Teresa Lewis
Previous Attendee [q. Yes
F/j No
Upload a image for your badge Select,File
This is an electronic form. You must fill in and print down this form from your browser if you wish to mail in your payment.
Please remit payment to the address below. You can submit payment from this form electronically if you so wish.
Please note that PaylPalis our credit card processing company. Due to card safety reasons you can only process on payment per day. If you have
multiple attendees and your trying to process a credit card transaction you will be unable to do so. This is for your security. Please pay only one student
per day.
Remit Registration if mailed to:
The Georgia F.O.G Alliance
P.O.Box 4
Griffin,Georgia 30224
Attn:Treasurer
Make Checks Payable to:The Georgia F.O.G Alliance
(Tax I.D.Number 06-1773755)
Terms and Conditions:Refunds&Cancellations: All cancellations must be received in writing via mail. No phone cancellations will be accepted After 04
-01-13 registrants are no longer eligible for refunds,substitution registrants are permitted.
NO REFUND FOR THOSE WHO REGISTER AND FAIL TO ATTEND.
By submitting this document either by mail or electronic payment I agree to th terms of this registration:
Electronic Signature:•
Today's Date:* 44�-13
Proceed to Checkout aftimmum-mm Paypar
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µ ` ACCOUNTS PAYABLE VOUCHER
Prescribed by State Board of Accounts
" Form No.301-S(Rev.1995)
TO
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Invoice Date Invoice Number Item Amount
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 except
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Signature Title
I hereby certify that the attached invoice(s), or bill(s), is (are) true and corre t and I have audited same in accordance
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ACCOUNTS PAYABLE DETAILED ACCOUNTS
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