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Home My WebLink About221203 06/18/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1 ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $2,090.64 CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 INDIANAPOLIS IN 46204 CHECK NUMBER: 221203 CHECK DATE: 6/18/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 R4340701 25505 20506 370 . 13 PHYSICALS 1110 R4340701 25482 20507 675 . 19 PHYSICAL FOR APPLICAN 1110 4341999 20555 65 . 07 OTHER PROFESSIONAL FE 1110 R4340701 25505 20555 980 . 25 PHYSICALS I INVOICE o Public Safety Medical Services 324 E. New York Street E Suite 300 w Indianapolis, IN 46204 C Carmel Police Department/CARMEPD F" 3 Civic Square Terms Carmel, IN 46032 Invoice Date 06/03/2013 m Invoice# 00-20506 Date Employee Description Amount Balance Due 05/31/13 Madden.Timothy J. Chart Review/Completion $85.94 $85.94 Indiana PERF Exam $193.13 $193.13 Drug Screen 9 +Opiates&Ox codone $42.45 $42.4 5 Applicant Blood Panel-PERF $121.84 $121.84 Tb Skin Test $7.43 $7.43 Veni uncture $3.19 $3.19 PSY-Applicant Psych Eval $360.00 $360.00 Tonomet Glaucoma Test 38.20 $38.2 0 Urinalysis-Di stick $3.19 $3.1 9 EKG W/Inter 21.22 $21.22 A 14 4. PFT-Pulmonary Function Test $35.02 $35.02 Vision-Color Ishihara 27.59 $27.59 Vision-Acuity $27.59 $27.59 Vital Signs-HT WT BP P R $0.00 $0.001 Chest X-Ra -PA/LAT(Digital) 63.67 $63.67 Total Charges->1 $1,045.32 Total Payments&Balance Due-> $0.00 1 $1,045.32 Please write invoice number on payment check. Balance Due 15 days from invoice Our Federal Employer Identification Number is 35-2079797 date I i INVOICE H Public Safety Medical Services ._. 324 E. New York Street E Suite 300 � Indianapolis, IN 46204 C Carmel Police Department/CARMEPD E' 3 Civic Square Terms Carmel, IN 46032 Invoice Date 06!12/2013 m Invoice# 00-20555 Date Employee Description Amount Balance Due 06/04/13 Morris James D. Chart Review/Completion $85.94 $85.9 4 Indiana PERF Exam $193.13 $193.13 Applicant Blood Panel-PERF $121.84 $121.84 Chest X-Ra -PA/LAT(Digital) 63.67 $63.67 Veni uncture $3.19 $3.19 Drug Screen 9 +Opiates&Ox codone $42.45 $42.4 5 Tonomet Glaucoma Test 38.20 $38.20 Urinalysis-Dipstick $3.19 $3.19 EKG W/Intem $21.22 $21.2 2 Audiornetry $14.86 $14.86 PF -Pulmonary Function Test $35.02 Vision-Color Ishihara $27.59 $27.59 Vision-Acuity $27.59 $27.5 9 Vital Signs-HT WT BP P R $0.00 $0.00 Tb Skin Test $7.43 $7.43 PSY-Applicant Psych Eval $360.00 $360.00 Total Charges-> $1,045.32 Total Payments&Balance Due-> $0.00 $1,045.32 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 ® II Carmel CERTIFICATE NO.003120155 002 0 11 PURCHASE ORDER NUMBER FEDERAL EXCISE TAX EXEMPT 35-60000972 ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,A/P CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS, FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL-1997 SHIPPING LABELS AND ANY CORRESPONDENCE. PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION 9=20`12 Public Safety Medical Services Camel Police Department VENDOR SHIP 3 Civic Square TO 324 E. Now York SIFeet, Smite SW Camel, IN 4 Indianapolis, IN 46 (397)671 CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION Account 43.407.01 9 Each physical for applicant $675.19 $675.19 Sub Total: $675.19 fu Lucas Gosson f-� �0 00 ` I Send Invoice To: Camel Police Department Attn: Teresa Anderson 3 Civic Squam Camel, IN 46032- PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT Cannel Police Dept. PAYMENT $675.19 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 CERTIFY 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 �t 7Jj' •PURCHASE ORDER NUMBER MUST APPEAR ON ALL s SHIPPING LABELS. lof of Police •THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. CLERK-TREASURER DOCUMENT CONTROL NO. 4A. . . COPY-SIGN AND RETURN TO CLERK'S OFFICE VOUCHER NO. WARRANT NO. ALLOWED 20 IN THE SUM OF $ 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 except I 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund f 0 INDIANA RETAIL TAX EXEMPT Cily PAGE C CERTIFICATE NO.003120155 002 0 of. PURCHASE ORDER NUMBER FEDERAL EXCISE TAX EXEMPT 2550 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 NO. VENDOR NO. DESCRIPTION Public Safety Medical Sawicos Carmel Polico Cep2ittm nt VENDOR SHIP 3 Clvlc Squam 324 E. Now York Stmot, Suit@ 3M TO Cumol, IN Indlarrapolls, IN 46204 (317)671-2M9 CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION Account 43-407.09 2 Each physical for applicard $675.19 $9,350.38 Sub Total: $1,350.38 5706 Jonathan Rico I Christopher Bay Send Invoice To: C 1 e1 Pollco Attu: Teresa Anderson 3 Ciyle €guava Cannel, IN 4t PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT I PROJECT ACCOUNT AMOUNT Carmel Police Dept. C j PAYMENT $1,M.38 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 CERTIFY THAT THERE•IS AN UNOBLIGATED BALANCE IN THIS APPROPRIATION SHIP REPAID. ON SUFFICIENT TO PAY FOR THE ABOVE ORDER. • . •C.O.D.SHIPMENTS CANNOT BE ACCEPTED. ORDERED BY / r •PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABELS. 0 h{(€ Poll+ •THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. V U CLERK-TREASURER DOCUMENT CONTROL NO. A.___PPP.V COPY-SIGN AND RETURN TO CLERK'S OFFICE VOUCHER NO. WARRANT NO. ALLOWED 20 IN THE SUM OF $ 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 except. _ - -- -- ...------ ------- 20 .....------------ --- ------- —- ------ ---- Signature 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)) 06/03/13 20506 applicant physical-Madden $370.13 06/03/13 20507 applicant physical $675.19 06/12/13 20555 applicant physical- Morris $65.07 06/12/13 20555 applicant physical- Morris $980.25 I 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. ALLOWED 20 Public Safety Medical Services IN SUM OF $ 324 E. New York Street, Suite 300 Indianapolis, IN 46204 $2,090.64 ON ACCOUNT OF APPROPRIATION FOR Carmel Police Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT � Board Members Encumbered I hereby certify that the attached invoice(s), or 25505 20506 43-407.01 $370.13 - Encumbered bill(s) is (are) true and correct and that the 25482 20507 43-407.01 $675.19 materials or services itemized thereon for 1110 20555 43-419.99 $65.07 which charge is made were ordered and Encumbered 25505 20555 43-407.01 $980.25_ received except Friday, June 14, 2013 Chief of Police Title Cost distribution ledger classification if claim paid motor vehicle highway fund