222431 07/30/2013 CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1
0 *f ONE CIVIC SQUARE HENRY SCHEIN INC
: CARMEL, INDIANA 46032 DEPT CH 10241 CHECK AMOUNT: $2,013.00
% ? PALATINE IL 60055-0241 CHECK NUMBER: 222431
CHECK DATE: 7/30/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 3389587-01 2, 013 . 00 SPECIAL DEPT SUPPLIES
11021757 07/11/13 08/10/1 3
uoB#:01-243-0880
wxseoE*# RHO]oz*v4 Fed ID: ||'3|smy5
rhis order aas been processed by our MIDWEST D.C.
INDIANAPOLIS,IN 46268
vlARK 317-57L-2663
1 602-8100 EA COLLAR STIFNECK SELECT ADULT 100 100 C 5.75 575.00 2
CASE GOOD IFEM, MAY BE SHIPPED SEPARATELY.
CASE GOOD ITEM, MAY BE SHIPPED SEPARATELY.
14N - PEDIGREE ITEM.
CASE GOOD I—EM, MAY BE SHIPPED SEPARATELY.
4 499-0472 PU EA MECONIUM ASPIRATOR 12 12 4.10 49.20 11
CASE GOOD ICEM, MAY BE SHIPPED SEPARATELY.
14N - PEDIGRE ITEM.
7 890-6800 EA SHARPS SHUTTLE SINGLE USE P2 50 50 1.58 79.00 11
8 857-6066 EA NASAL AIRWAY LF 32FR is 15 2.40 36.00 11
BILL TO SH12 TO INVOICE# INVOICE AM 11 ITEM STATUS KEY REM KEY
B-Backordered:Item will follow S C School Kit
11308571 1817102 3389587-01 2013 . 00 D-Discontinued:Item no longer available C No Charge
F-Special Schein Five Goods
HSI ORT)ER# ORDER DATE — INVOICE DATE # OF 13OXES M-Manufacturer will ship Item directly to you
P prescription Drug:Return Authorization Required
11102175 7 07/11/13 7/11/13 11 R Refrigerated Item:May be shipped separately
1 $ Special Schein pricing
CUSTOMER 20# :::]1 PAGE# T Taxable Item
�:Temporarily unavailable:please reorder
MARK 1 OF Item has MSDS Continued on Next Page..........
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2 HENRY SCHEIV
S SHIP TO/SOLD TO:
EMS Carmel Fire Department MI
135 Duryea Road, Melville, NY 11747 INVOICE 540 W 136th St
Station 46 Michael Kaufmann
Carmel,IN 46032-8806
0100001308571,03389587110010000002013000711139 BILL TO:
Carmel Fire Dept MI
2 Civic Sq
Carmel, IN 46032-7543
Carmel Fire Dept
2 Civic SCI BILL TO SHIP TO T INVOICE AMOUNT
Carmel, IN 46032-7543 1308571 1817102 1 2013 .00
INVOICE INVOICE DATE_-]
3389587-01 7/11/13
CUSTOMER PO
MARK
Please detach here and inA the above with your payment
HSI ORDER# ORDER. DATE DUE DATE
11021757 07/11/13 08/10/13
D&B#:01-243-0880
WHSE DEA# RH0162494 Fed ID: 11-3136595
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9 555-8102 PU EA PROTECTIV ACUVNC SFT CATH 16X1.25 50 50 2.23 111.50 11
10 153-6648 100/BX BIOHAZARD BAG 23X23 RED 23 1IX23" 4 4 C 11.00 44.00 10
ASE GOOD I EM, MAY BE SHIPPED SEPARATELY.
11 496-6428 100/BX LANCET SURGILANCE GRAY 23G 1.8 3 3 * 9.95 29.85 11
F YOU ARE DARTICIPATING IN A DISCOUNT PROG (E.G. POIN S, GIFTS OR O HER
PECIAL AWA DS ("DISCOUNT")) , WITH THIS PURL SE YOU HAVE EARNED A CREDI TOWARD
GOODS OR SERVICES, RECEIVABLE OR REDEEMABLE IN ACCO DANCE WITH DISCOUNT PROGRAM
RULES. UPOW DISCOUNT RECEIPT OR REDEMPTION, 'IOU ARE RECEI ING OR WILL R CEIVE
OTICE OF TIE DISCOUNT VALUE. FROM TIME TO TIME, MEDICARE, MEDICAID, TRI ARE OR
THER PAYER MAY REQUEST INFORMATION REGARDING SUCH V LUE, D UPON ANY S CH
EQUEST, SU H VALUE MUST BE DISCLOSED AS A DI COUNT AGAINSI THE PURCHASES THAT
ARNED SUCH VALUE. ACCORDINGLY, YOU SHOULD RE AIN THESE RECORDS.
N - HENRY 3CHEIN, INC. HAS PURCHASED THE SPE IFIC UNIT OF THE PRESCRIPTION DRUG
DIRECTLY F OM THE MANUFACTURER.
MERCHANDI E TOTAL 2013.00
Invoice Date + 30 days 2013.00
Please remi payments only to the following a dress:
enry Schei , Inc.
ept CH 10211
alatine, I 60055-0241
,ILL TO SHIP INVOICE# INVOICE AMOUNT ITEM STATUS KEY FREEM KEY
II-Backordered;Item will follow School Kit
0 8 5 71 181710 2 3 3 8 9 5 8 7-01 2 013 .0 0 D-Discontmued;Item no longer available -No Charge
F-Special Schein Free Goods
QRDER# ORDER NV DATE # OF BOXES M-Manufacturer will ship Item directly to you
P-Prescription Drug;Return Authorization Required
)217 5 7 07/11/13 7/11/13 11 R -Refrigerated Item:May be shipped separately
$ -Special Schein Pricing
CUSTOMER PO# PAGP# j T-Taxable Item
U-Temporarily unavailable:please reorder
ARK 2 OF 2 + -Item has MSDS
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We make every effbrtNmaintain prices for 1he duration da Payment by CHECK or by the HENRY SCHEIN CREDIT CARD,
catalog,however.wereaomo the right'to make price adjustments in VISA,MASTERCARD,DISCOVER and AMERICAN EXPRESS
response to manufacturers'price changes
Guaranteed Satisfaction:
or
8 you have tried a product and itio defective ur does not perform 1301 Your Ordet To Your Open Account
satisfactorily,wo will provide a credit,refund,or exchange;it's your
choice. Simply call our customer service department within 30days payable within 30 days.
of receipt of the merchandise to arrange for the return. For
warranty mpairorif you were sent something you did not order,
simply call:� Rx Products & Controlled Substances:
Matrx@ledical 1-800'845-3550
Regulations require uatulimit the sale ofRx and controlled
substances only to registered,licensed healthcare professionals.
If you a,re a new Customer or have recentl moved,please furnish
us with a copy of your updated state registration. For controlled
substances,furnish a copy of your DEA certificate,verifying your
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International Orders:
Please Note:
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umdi\.bu\wi||be�paimdnrrep|aoediououu�anoo�i1h \nrmsandvondihnnu.p|eu000nn�ctour|ntnmohon�Depa�men�
manu�ao\uerwur�nheo�8o�orenponinghmndpieoeuor 1'80O'845'35�U
equipment, ouuggo��� check the ship i container
and packing list to verity that you have received exactly what Py8scri�tioM ��yW� ���yM� �M�t/W��i�D�''
you o�eredO dCnm t Sohworeisnotreturnob|o. ��
Other restrictions may also apply.
A Return Authorization io Required for all Prescription Drugs,Simply call
our Customer Service Department @1-808-84S-355Q,
,NO ft, :
Lpxoo
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))
3389587-01 $2,013.00
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 NO. WARRANT NO.
ALLOWED 20
Henry Schein
IN SUM OF $
Dept Ch 10241
Palatine, IL 60055
$2,013.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I 3389587-01 1 102-390.11 I $2,013.00 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
Fire Chi
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund