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223962 09/10/2013 CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1 ONE CIVIC SQUARE HENRY SCHEIN INC CHECK AMOUNT: $3,487.57 CARMEL, INDIANA 46032 DEPT CH 10241 PALATINE IL 60055-0241 CHECK NUMBER: 223962 CHECK DATE: 9/10/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 4239011 8298613-01 3 , 167 . 57 SPECIAL DEPT SUPPLIES 102 4239011 8302334-01 320 . 00 SPECIAL DEPT SUPPLIES Please detach here and mail the above with your payment HSI ORDER# ER DATE DUE DATE 12235391 08/28/13 1 09/27/13 DEA# STATE REG D&B#:01-243-0880 WHSE DEA# RHO 162494 Fed ID: 11-3136595 01053866A AM " 9...... �.:.. ..�.. ....,....._..-ter .�..... ,.:emu«::�:>. _..> .WO RR a...n �.�. s, .z.. ..:��::�•::�-• .. �.. )) �w�........ ..,_ .....�.....�<�:... .,.:Q`.4 .s .. .. „ . ...... ...�...... 53 4 E 8 .fib x, "::x` .�,�( •sv�y,3!':i : .x 1��.-...as � •�Y�...r�.r. ::tttt::'r�',��., �ti :::�:">?a;'i s e.e ,.x' MERCHANDI E TOTAL 3167.57 nvoice Date + 30 days 3167.57 lease remi payments only to the following a dress: Henry Schei , Inc. Dept CH 10211 Palatine, I 60055-0241 BILL TO SHIP TO INVOICE INVOICE# INVOICE AMOUNT ITEM STATUS KEY REM KEY 1308571 1817102 8298613-01 3167 .57 H-Discontinued: Item will fogey N -No School Ch Kit D-Discontinued;Item no longer available NC-No Charge H I D R ORDER DA INV ATE BOXES Special Schein free Goods M-Manufacturer will ship Item directly m you P-Prescription Drug:Return Authorization Required 12 2 3 5 3 91 0 8/2 8/13 8/28/13 2S R-Refrigerated Item:May be shipped separately CUSTOMER PO PAGE S -Special Schein Pricing T-Taxable Item U-Temporarily unavailable:please reorder MARK 3 OF 3 t -hem has MSDS :'_�' -�..-*-,'' y#."--} nom= fir„" ;",,•�" _`��'- s�. „�ya�,'i$w"..�.,F�=�° .•4 - - .;,.. :y=;x,. .c',*�.: -.s��-i �h3;• �' 'err 4.-1��` ti-3`"�,':". "�' '",� = s� r; ^. �_ zy��, �� _ :c+ - k �.utit.+"�.�•'��'f.�,v 7,,.� �r,+-5. _ i q�' a��'� '��nh' mar; � "x^{ � `. � We make,every effc A°;;maintai prices far the duration of a Payment by CHECK or by the HENRY SCHEIN CREDIT CARD, catai?a, oL,rever, .•e reserve the ri ht to make Arica adjustments:tl VISA,MASTERCARD.DISCOVER and AMERICAN EXPRESS response to manufact€:rers'pricE hanges Guaranteed Satisfaction: visa. LA If liou.have tried a oroduct and it is defective or doest of oerform or Bill Y��ur satisfactorily,we vvill Provide a credit, refund,or exchange:it's your choice, Sirr ply gall Jur custon er sin.i e de:arty ent;xr thi 'c.0 days 4vaiiab'e.to liccrosed prac:tit ono s r:.t~ U.S.M �voic's are ' n v 1 for a �,3 payable with l:30 days., roi:t of thu'rnerch o`rea:,,dise to arrange or the rr;°urn. For a warranly r>einair or if you were sent something yo€i did not order, ;<r pIy call: Rx products & Controlled Substances: latrx Medical 1-800-845-3550 Regulatio%s require us to limit the sale of'?x and confroll d .substances o iv to'en€stared,licensed healthcare professionals. If you are a new customer or have rece?tly moved,please fur ish� us with a co-Dv of your updated stag registration. For controlled substances,h irnish a copy of your DEA certificate,verifyir g your shipping address- .;lass II drugs car:be ordered only by::ail, International Orders: Please Note ........ _ Opened handpieces and equipment may not be returned for We proudly serve health-care professionals an governments credit;b�t:=11 f e repaired .r replaced in ac c;,rda cc ^Jiih t roughout the word. `o pace orders or for !fires on export terms and conditions;:lease contact our I%°ernationai Departn-ient- manufacturer v^<Frrant s.BFfo re opening handp er,;s or '-800-845-3,HO equipment,we s€ggest that you check the shipping conlaine r aid ackind list to verify t„at you I?avR reoei Fd exactly what prescription Drug Returns Instructions: yogi crdered.Cpened Computer Software is not returnable, Other restrictions may also apply. A Return Authorization is Required for all Prescription t:r+.rgs. C3:1-ply call our Customer Service Department :1.800-84:5-3550. ...r:. r: �< r 'Sq' w..:........ �r ................ ...:::.... LP300 Please detach here and mail the above with your payment HSI ORDER# ORDER DATE jQ.E DATE 12235245 08/28/13 1 09/27/131 D&B#:01-243-0880 WHSEDEA# RHO162494 Fed ID: 11-3136595 gg.- .............. - M. N 204 11-1111 i m I 50111 This order has been processed by our MIDWEST D.C. 5315 WE Sr' 74TH 3TREET INDIANAP LIS,IN 46268 ---------- 1 600-4070 1/KT LARYGOSCOPE ASST BLADE KIT 4 4 80.00 320.00 1 THE PRICES TATED ABOVE MAY REFLECT A DISCOUN" OR BE SUBJECT TO A REBATE YOU AUST FULLY D ACCURATELY REPORT THIS STATED DISCOUN PRICE, OR IF APPLIWABLE, kNY NET PRIVING, AFTER GIVING EFFECT TO ANY REBATES, TO MEDICARE, MEDICAID, TRICARE AND ANY OTHER FEDERAL OR STATE PROGRAM UPON ZEQUESI BY ANY SUCH PROGRAM. IT ISYOUR ZESPONSIBILITY TO REVIEW ANY AGREEMENTS OZ OTHEF DOCUMENTS APFLICABLE TO THESE PZICES TO DETERMINE IF THEY ARE SUBJECT TO A REBPTE. THE FEDE L OVERNMENTIMPOSES CERTAIN RESTRICTIONS ON, AND REQUIZES PUELIC REPORTING OF, TRANSFERS O 'VALUE TO A PRACTITIONER. IF YOU ARE PARTICIPATING IN A PROMO DISCOUNT PR GRAM (E.G. POINTS, DISCOUNT REDEMPTIONS )R OTHER SPECIAL AWARDS) , 4ITH YOUR PJRCHASES YOU MAY EARN POINTS/CREDI .S REDEEMABLE FOR CERTAIN GOODS OR 3ERVICES, 14 ACCORDANCE WITH DISCOUNT PROGRAM RULES. UPON EISCOUNT RECEIPT BY REDEMPTION )F YOUR EARNED POINTS/CREDITS, YOU ARE RE"EIVINC OR WILL RECE VE .1MTICE OF T DISCOUNT VALUE. ACCORDINGLY, YOU SHOULD RETAIN THESE RECORMS. MERCHANDISE TOTAL 320.00 Invoice Date + 30 days 320.00 Please remi: payments only to the following address: Henry Scheia, Inc. Dept CH 102 1 Palatine, 1 60055-0241 BILL TO SHIP TO INVOICE11 INVOICE AMOUNT ITEM STATUS KEY REM KEY B B-Backordered:Item will follow ]RU� SK-School Kit HILL 1308572 8302334-01 320.00 1)-Discontinued:Item no longer available NC-No Charge I_ Special Schein Free Goods R ORDER DATE INVOICE DATE OF BOXES M-Manufacturer will ship Item directly to you P prescription Drug:Return Authorization Required 'r,Required 12235d245 08/28/13 8/28/13 1 R Refrigerated Item:May he shipped separately $ Special Schein Pricing CUSTOMER 0# PAGE T-Taxable Item U-Temporarily unavailable:please reorder MARK 1 OF 1 -Item has MSDS - We,make e��o��ma�x� Payment by CHECK or by the HENRY SCHEIN CREDIT CARD, natabg.huwove!'wm reserve the richi to make pri-camdjuuknnntsi: m VISA,MASTERCARD, DISCOVER and AMERICAN EXPRESS npnnnnto;manufacturers'Price uheo0oo Guaranteed Satisfaction: or Kxnu have k|adaDroduo|and i(}odo(eciveo/dnao:uipprfu�� nahubcfnNy,we*)||pmv|doaumdit m(ond,or exchange, chnico, Simp�oeUnorcuutumer service de U |wMhin2Oda,io payable within 30 days, omca�t,,f the morfhaodiooto arrangefor the return. Fora warranty ori|yo:were sent something yo:/UiUno\order o|�p}yma/|: Rx Products & Controlled Substances: MatrxMediDak 1-808~845~3550 Regulations requirnvoN limit the,oa|eotFx and controlled substances only to registered,licensed healthcare pmfeuuinna|s. |"you a re anew Customer or have recently moved, | furlish substances,fuMish a copy ot your DEA certificate,verify,liq shipping address, Class 11 drU(js Caln,be orderod..onlv b,,:y ail, International Orders: P1ease Note: e�hand�eco and" Wepm � hmdth pm�maiona{oandgmmmmonto `r-' ~ (hmuOhou\�ho�u�!d Tnp!anpu�e�nnrfm|nqo|n|annnoxpo� o�odii bu�wii|box/pai�odormp|a:odinucro�ancnwi|h � ' terms and conditions, |mmn�n��\nu/|r�r��i��Depa�meo�� men�w�u�rwnnanUeu,Ba�muponinghundplecmsnr 1�GO�4�86SO ' ' oov|pmnnt we 1ha| o ~h k|ho~nh' f i anopaomngnmmv�v ma�You^mm~ ~ aU exactly what YOU nrdeed.0penad Computer Software im not returnable, Prescription Drug Returns Instructions: bthmr restrictions may also apply, ARo|um Authorization is Required iorall Proon'iphnn Drugs.S|—p|ycall out,CuutonerService Dapo�meot 4�_-1800-84!5-35S0, LEY | u`300 HENRY SCHEWqD EMSCpA�C SHIP TO/SOLD TO: Carmel Fire Department MI 135 Duryea Road, Melville, NY 11747 INVOICE 540 W 136th St Station 46 Michael Kaufmann Carmel,IN 46032-8806 0100001 30857108298613110010000003167570828130 BILL TO: Carmel Fire Dept MI 2 Civic Sq Carmel, IN 46032-7543 Carmel Fire Dept BILL To I SHIP TO INVOICE AMOUNT 2 Civic Sq Carmel, IN 46032-7543 1308571 1817102 1 3167.57 INVOICE# INVOICE DATE 8298613-01 8/28/13 CUSTOMER PO# MARK HSI ORDER# I ORDER DATE DUE DATE 12235391 08/28/13 1 09/27/13 DEA# STATE REG# D&B#:01-243-0880 WHSEDEA# RHO 162494 Fed ID: 1 1-31 36595 CONTAINS MULTIPLE INVOICES 01053866A WON F: �> N his order ias been processed by our MIDWEST D.C. 5315 WES 74TH 3TREET INDIANAP LIS,IN 46268 1 107-0502 100/BX PURPLE NITRILE PF GLOVE MEDIUM 40 40 *C 8.50 340.00 4 ASE GOOD I EM, MAY BE SHIPPED SEPARATELY. 2 107-0530 100/BX PURPLE NITRILE PF GLOVE LARGE 80 80 *C 8.50 680.00 12 ASE GOOD I EM, MAY BE SHIPPED SEPARATELY. 3 107-0540 90/BX PURPLE NITRILE PF GLOVE X-LARGE 50 50 *C 8.50 425.00 17 ASE GOOD I EM, MAY BE SHIPPED SEPARATELY. 4 507-0791 U EA IV ADMIN SET 15DROP W/NDL INJ SIT 200 200 C 1.57 314.00 21 ASE GOOD I EM, MAY BE SHIPPED SEPARATELY. 5 555-1166 U EA PROTECTIV ACUVNC SFT CATH 18X1.25 100 100 2.23 223.00 23 6 555-5396 PU EA PROTECTIV ACUVNC SFT CATH 20X1.25 250 250 2.23 557.50 23 7 555-4687 PU EA PROTECTIV ACUVNC SFT CATH 22GX1" 100 100 2.23 223.00 25 HIS PRODUCU IS BEING SHIPPED FROM OUR SOUTHE ST DIS17RIBUTION CENTER. 8 507-8362 100/BX NACL PREFILL SYRINGE 10ML ST 3 3 40.00 120.00 23 N - PEDIGREE ITEM. .IIDC:6380701)010 9 496-6428 100/BX LANCET SURGILANCE GRAY 23G 1.8 3 3 * 9.95 29.85 24 BILL To SHIP TO INVOICE4 INVOICE INVOICE AMOUNT ITEM STATUS KEY REM KEY 1308571 1817102 Ii-Backordered:Item will follow SK-School Kit 8 2 9 8 613-01 3 1 6 7 .5 7 U-Discontinued:Item no longer available \C-No Charge I' fre -Special Schein e Goods HSI QRDER# ORDER DATE INVOICE ATE # OF 13OXES M-Manufacturer will ship Item directly to you 1'-Prescription Drug:Return Authorization Required 12235391 08/28/13 8/2 8/13 25 R -Refrigerated Item:May be shipped separately $ -Special Schein Pricing CUSTOMER PAGE T-Taxable Item U-Temporarily unavailable:please reorder MARK 1 OF 3 ` -Item has MSDS Continued on Next Page.......... E W� 2 HENRY EI ( 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 0100001308571082986131,1001,0000003167570828130 BILL TO: Carmel Fire Dept MI 2 Civic Sq Carmel, IN 46032-7543 Carmel Fire Dept BILL To I SHIP TO INVOICE AMOUNT 2 Civic Sq Carmel, IN 46032-7543 1308571 1817102 1 3167 .57 INVOICE# INVOICE DATE 8298613-01 8/28/13 CUSTOMER PO# MARK HSI ORDER# ORDER DATE DUE DATE 12235391 08/28/13 1 09/27/13 DEA# STATE REG# D&B#:01-243-0880 WHSEDEA# RHO162494 Fed I D: 11-3136595 01053866A P" N. :::g> u...... . .....,. � , . ...........>::: .... .. y r 10 499-8529 EA BVM RESUSCITATOR DISP ADULT 20 10 9.95 99.50 24 ARTIAL SHI MENT - WILL SHIP AND INVOICE WHEN AVAILA LE. 11 648-9088 12RL/BX MEDIRIP BANDAGE 2"X5YD 4 4 21.93 87.72 24 12 220-2270 EA THOMAS HOLDER F/ET TUBE ADULT 25 25 2.72 68.00 23 ---------- --------------------------------- ------ ----- ------------- ------- HE PRICES 3TATED ABOVE MAY REFLECT A DISCOUN OR BE SUBJECT TO A REBATE YOU UST FULLY D ACCURATELY REPORT THIS STATED DISCOUNT PRICE, OR IF APPLI ABLE, Y NET PRI ING, AFTER GIVING EFFECT TO ANY REBATES, TO ME ICARE, MEDICAID, RICARE AND ANY OTHER FEDERAL OR STATE PROGRAII UPON ZEQUESl BY ANY SUCH PROGRAM. IT ISYOUR ESPONSIBILITY TO REVIEW ANY AGREE ENTS O OTHEF DOCUMENTS AP LICABLE TO THESE P ICES TO DETERMINE IF THEY ARE SUBJECT TO A REB TE. THE FEDE L OVERNMENTI POSES CERTAIN RESTRICTIONS ON, AND REQUI ES PU LIC REPORTING OF, RANSFERS 0 VALUE TO A PRACTITIONER. IF YOU ARE PARTICIPATING IN A PROMOTIONAL ISCOUNT PR GRAM (E.G. POINTS, DISCOUNT REDEMPTIONS R OTHER SPECIAL AWA DS) , ITH YOUR P RCHASES YOU MAY EARN POINTS/CREDI S REDEERMABLE FOR CERTAIN G ODS OR ERVICES, 14 ACCORDANCE WITH DISCOUNT PROGRAM RULES. UPON EISCOUNT RECEI T BY EDEMPTION F YOUR EARNED POINTS/CREDITS, YOU ARE RE"EIVINC OR WILL RECEIVE OTICE OF T E DISCOUNT VALUE. ACCORDINGLY, YOU SHOUL RETAIN THESE RECOR S. N - HENRY 3CHEIN, INC. HAS PURCHASED THE SPECIFIC UNIT OF THE PRESCRIPT ON DRUG DIRECTLY F OM THE MANUFACTURER. ---------- --------------------------------- ------ ----- ------------- ----- ---------- --------------------------------- ------ ----- ------------- ----- Southeast D stribution Center 691 JESSE 3 SMITH CT JACKSONVILLE, FL 32219 ICENSE #: 2:01315 BILL TO SHIP To INVOICE# INVOICE AMOUNT ITEM STATUS KEY REM KEY B-Backordered:Item will follow SK-School Kit 1308571 1817102 8298613-01 316 7 .5 7 D-Discontinued:Item no longer available NC-No Charge P-Special Schein Free Goods HS DER RD R DATE INVOICE DATE F ES M-Manufacturer will ship Item directly to you P-Prescription Drug:Return Authorization Required 12235391 08/28/13 8/2 8/13 25 R -Refrigerated Item:May be shipped separately $ -Special Schein Pricing S MER PO PA QE T-Taxable Item U-Temporarily unavailable:please reorder MARK 2 OF 3 Item has MSDS Continued on Next Page.......... 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)) 8302334-01 $320.00 8298613-01 $3,167.57 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 Henry Schein IN SUM OF $ Dept Ch 10241 Palatine, IL 60055 $3,487.57 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1120 j 8302334-01 102-390.11 $320.00 1 hereby certify that the attached invoice(s), or 1120 1 8298613-01 102-390.11 $3,167.57 bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received exceptSER 7=,9 ,n„ Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund