219828 05/07/2013 CITY OF CARMEL, INDIANA VENDOR: 204038 Page 1 of 1
ONE CIVIC SQUARE MIDWEST TOXICOLOGY SVS,INC
CARMEL, INDIANA 46032 603 E WASHINGTON ST SUITE 200 CHECK AMOUNT: $69.00
INDIANAPOLIS IN 46204 CHECK NUMBER: 219828
CHECK DATE: 517/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4341999 8736 34 . 00 OTHER PROFESSIONAL FE
1120 4340799 9411 35 . 00 OTHER MEDICAL FEES
Midwest 7oxicoCogy Invoice
(��. Services,LLC
OO,p% s
Payment Due Date Invoice#
d' f
603 E.Washington Street,Suite 200,Indianapolis,IN 46204 Upon Receipt 4/11/2013 8736
Bill To Ship To
City of Carmel Names & location of collection
Attn: Jim Spelbring on invoices - no ss#!!
1 Civic Square Email results to Barb Lamb & cc Jim .
Carmel, IN 46032 Still Mail results to Jim
P.O. Number Project/JobsitP Control ` Rep
5528 DAC
Qty. Item Code Description Price Each Class Amount
2 ND Drug Tesf CS Non-DOT Drug Test 55.00 Indiana 110.00
Collected at Community Occ. Health Center(MedCheck)-Carmel
4/7/13
Anthony Johnson
4/8/13
Eric Schildmeier
1 ND Alcohol CS Non-DOT Alcohol Test 28.00 Indiana 28.00
Collected at Community Occ. Health Center(MedCheck)-Carmel
4/4/13
Bryan Hood
1 CS Surcharge Alcohol Please note that you are being charged an additional fee due to your 6.00 Indiana 6
collection site breath alcohol charges.
A finance charge will be assessed on all invoices not paid in 30 days.Thank you for your business!
Make checks payable to:Midwest Toxicology Services,LLC Total $144.00
For questions regarding this invoice,contact us at 317-269-3029 or fax us at 317-262-2222.Be sure to visit our website at www.midwesttoxicology.com
VOUCHER NO. WARRANT NO.
ALLOWED 20
Midwest Toxicology Services, Inc.
IN SUM OF $
603 E. Washington Street, Suite 200
Indianapolis, IN 46204
$34.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 8736 43-419.99 $34.00
I hereby certify that the attached invoice(s), or
I I I
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
Wednesday, May 01, 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))
04/11/13 8736 fit for duty/Hood $34.00
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
�tiQwesc 7o icofogy Invoice
(� Services,LLC
Date Invoice#
Payment Due
Upon Receipt 4/1812013 9411
603 E.Washington Street,Suite 200,Indianapolis,IN 46204
Bill To Ship To
City of Carmel Names&location of collection
Attn:Jim Spelbring on invoices-no ss#!!
1 Civic Square Email results to Barb Lamb &cc Jim .
Carmel, IN 46032 Still Mail results to Jim
P.O. Number Project/Jobsite Control-# -Rep 5528 DAC
Qty. Item Code Description Price Each Class Amount
1 DOT Alcohol CS DOT Breath Alcohol Test 28.00 Indiana 28.00
Collected at St.Vincent Carmel Hospital
8/27/12
Robert VanVoorst
1 CS Surcharge Alcohol Please note that you are being charged an additional fee due to your 7.00 Indiana 7.00
collection site breath alcohol charges.
Note: During account audit we found this test had not been invoiced. If you
have any questions,please call MRO Team D at 317-269-3035.
A finance charge will be assessed on all invoices not paid in 30 days.Thank you for your business!
Total $35.00
Make checks payable to:Midwest Toxicology Services,LLC
For questions regarding this invoice,contact us at 317-269-3029 or fax us at 317-262-2222.Be sure to visit our website at www.midwesttoxicology.com
VOUCHER NO. WARRANT NO.
ALLOWED 20
Midwest Toxicology
IN SUM OF $
603 E. Washington Street, Ste. 200
Indianapolis, IN 46204
$35.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I 9411 I 43-407.99 I $35.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
MAY -$ .2013
Fire Chief
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))
9411 $35.00
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