223575 08/27/2013 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: $34.00
INDIANAPOLIS IN 46204
CHECK NUMBER: 223575
CHECK DATE: 8/27/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1201 4358800 19060 34 . 00 TESTING FEES
-s� Invoice
9ytufwest 4"oxicoCo —'-
Services,LGC y �z`��
Payment Due Date Invoice#
603 E.Washington Street,Suite 200, Indianapolis,IN 46204 Upon Receipt 8/9/2013 19060
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 CKR
Qty. Item Code Description Price Each Class Amount
1. DOT Alcohol CS DOT Breath Alcohol Test Collected at Medcheck Carmel 28.00 Indiana 28.00
03/20/2013
1 CS Surcharge Alcohol Please note that you are being charged an additional fee due to your 6.00 Indiana 6.00
collection site breath alcohol charges.
Note: During an account audit we found this test had not been invoiced. If
you have any questions,please call 317-269-3035.
u
D
AUG 2 6 2013
By
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 $34.00
For questions regarding this invoice,contact us at 317-269-3029 or fax us at 317-262-2222.Be sure to visit our website at www.midwesttoxicology.com
VOUCHER NO. WARRANT NO.
ALLOWED 20
Midwest Toxicology
IN SUM OF$
603 East Washington Street, Suite 200
Indianapolis, IN 46204
$34.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel HR Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1201 19060 43-588.00 $34.00
hereby certify that the attached invoice(s), or
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
Monday, August 26, 2013
Z 1
Director, HR
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))
08/09/13 19060 $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