223616 08/27/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $1,045.32
�l+a CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
•ti.rod Via` INDIANAPOLIS IN 46204 CHECK NUMBER: 223616
CHECK DATE: 8/27/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4341999 25368 21051 1, 045 . 32 PHYSICAL
INVOICE
o Public Safety Medical Services
2e 324 E. New York Street
:E- Suite 300
Indianapolis, IN 46204
o Carmel Police Department/CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 08/14/2013
m Invoice# 00-21051
Date Employee SSN/lD :Description Amount Balance Due
08/05/13 Sharp,Spencer K. 637-01-3244 Chart Review/Completion $85.94 $85.94
Indiana PERF Exam $193.13 $193.13
Drug Screen 9 +Opiates&Ox codone $42.45 $42.45
A licant Blood Panel-PERF $121.84 $121.84
Tb Skin Test $7.43 $7.431
Veni uncture $3.19 $3.19
Chest X-Ray-PA/LAT(Digital) $63.67 $63.67
Tonomet Glaucoma Test 38.20 $38.20
Urinal sis-Dipstick $3.19 $3.19
EKG W/Intern $21.22 $21.22
Audiometry 4 14.8
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 $0.00
PSY-Applicant Psych Eval $360.00 $360.00
Total Charges->`1 $1,045.32
Total Payments&Balance Due-> $0.00 1 $1,045.32
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797
INDIANA RETAIL TAX EXEMPT PAGE
City o C ar}�'�e i CERTIFICATE NO.003120155 002 0 1i �/ 1il<li 1� PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 460.32-2554 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
7141 0i3
Public Rafety Modleal Soryicos Cafmol Police Department
VENDOR TOIP .3 Civic Square
324 E. New York Stmat, Suite 300 Cannel, IN 4
Indianapolis, IN 46204 (317)571-2,%g
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
,�y
QUANTITY �g UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account d34iOJI
9 Each phyt cal for applicant $575.19 $073.19
i Each psychological evaluation $370.13 $370.13
�r Stab Total: $1,045.32
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Send 8In o c To hard f
a
Carmel Police Department
Attn: Teresa Anderson
3 Civic Square
Cann @I, IN 4 2- PLEASE INVOICE IN DUPLICATE
DEPARTMENT r ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Cannel Police Dept. PAYMENT $1,045,32
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY TT •HERE IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIATIO
SHIP REPAID. N UFFICIENT TO PAY FOR THE ABOVE ORDER.
•
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED. ORDERED BY //
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL /
V
SHIPPING LABELS.
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE c9of of
Police
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
CLERK-TREASURER
DOCUMENT CONTROL NO. A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO. WARRANT
ALLOWED 20
IN THE SUM OF$
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$1,045.32
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
25368 I 21051 I 43-419.99 I $1,045.32 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
/
Thursday, August 22, 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))
08/14/13 21051 physical/psych- Sharp $1,045.32
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