224520 09/25/2013 CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1
ONE CIVIC SQUARE HENRY SCHEIN INC CHECK AMOUNT: $99.50
4,=0 CARMEL, INDIANA 46032 DEPT CH 10241
'''<•uH Zo� PALATINE IL 60055-0241 CHECK NUMBER: 224520
CHECK DATE: 9/25/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 8298613-02 99 . 50 SPECIAL DEPT SUPPLIES
HSI ORDER# I ORDER DATE IDUE DATE
12235391 1 08/28/13
D&B#:01-243-0880
WHSE DEA# RHO162494 Fed ID: 11-3136595
,W. 0
ma
This order has been processed by our MIDWEST D.C.
5315 WES'' 74TH 3TREET
INDIANAP LIS,IN 46268
1 499-8529 EA BVM RESUSCITATOR DISP ADULT 10 10 C 9.95 99.50 1
ASE GOOD ICEM, MAY BE SHIPPED SEPARATELY.
THE PRICES 3TATED ABOVE MAY REFLECT A DISCOUN" OR BE SUBJECT TO A REBATE YOU
4UST FULLY D ACCURATELY REPORT THIS STATED UISCOUNF PRIC , OR IF APPLI('ABLE,
kNY NET PRI-ING, AFTER GIVING EFFECT TO ANY REBATES, TO MEDICARE, MEDICAID,
rRICARE AND ANY OTHER FEDERAL OR STATE PROGRAII UPON ZEQUESq BY ANY SUCH PROGRAM.
IT ISYOUR ZESPONSIBILITY TO REVIEW ANY AGREEMENTS OZ OTHEF DOCUMENTS APPLICABLE
TO THESE PZICES TO DETERMINE IF THEY ARE SUBJECT TO A REBPTE. THE FEDERAL
OVERNMENTIIPOSES CERTAIN RESTRICTIONS ON, AN REQUIZES PUELIC REPORTING OF,
TRANSFERS OFVALUE TO A PRACTITIONER. IF YOU ARE PART ECIPATING IN A PROMO
DISCOUNT PR GRAM (E.G. POINTS, DISCOUNT REDEMPTIONS )R OTHER SPECIAL AWAImS) ,
RITH YOUR PJRCHASES YOU MAY EARN POINTS/CREDIS REDEEMABLE FOR CERTAIN GOODS OR
SERVICES, 14 ACCORDANCE WITH DISCOUNT PROGRAM RULES. UPON EISCOUNT RECEIPT BY
REDEMPTION )F YOUR EARNED POINTS/CREDITS, YOU ARE RE"EIVING OR WILL RECEIVE
.\IOTICE OF T DISCOUNT VALUE. ACCORDINGLY, YO J SHOULD RETAIN THESE RECORDS.
N - HENRY =EIN, INC. HAS PURCHASED THE SPE'IFIC IT OF THE PRESCRIPT ON DRUG
DIRECTLY FROM THE MANUFACTURER.
-------------
MERCHANDI E TOTAL 99.50
Invoice Date + 30 days 99.50
BILL TO SHIP TO INVOICE INVOICE AMOUNT ITEM STATUS KEY KEY
1308571 1817102 B-Backordered:Item will follow K-S hotd K it
8298613-02 99.50 1)-Discontinued:Item no longer available
I_ free Goods NC-No Charge
Special Schein I- U I Coo a 11
HSI QRDER#< ORDER DATE INVOICE DATE # OF BOXES M-Manufacturer will ship Item directly to you
1) Prescription Drug:Return Authorization Required
12235391 08/28/13 8/30/13 1 R Refrigerated Item:May be shipped separately
-
$ Special Schein Pricing
CUSTOMER PO PAGE T Taxable Item
U-Temporarily unavailable:please reorder
MARK 1 OF 2 -hem has MSDS Continued on Next Page..........
LP300
�',"r�HEN R I SCHEIN"'
SHIP TO/SOLD TO:
EMSCarmel Fire Department MI
135 Duryea Road, Melville, NY 11747 ® 0®� 540 w 136th St
yy Station 46 Michael Kaufmann
Carmel,IN 46032-8806
0100001308571082986131],0020000000099500830137 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 99 .50
INVOICE# INVOICE DATE
8298613-02 8/30/13
CUSTOMER PO#
- - MARK- - - — �-
please detach here and mail the above with your payment
HSI ORDER# I ORDER DATE IDUE DATE
12235391 08/28/13 09/29/13
D&B#:O 1-243-0880
WHSE DEA# RHO162494 Fed ID: 11-3136595
;: 3- '' .:3?'13 �•�•.= t1', .: a ��-:.�£t•yt £ui:25r' ; ,;
..�..,, .�nre s-,* .•s....ss.:::... _. „••.••,,.,�,rI.t:=K ' •..w•••...:. ��r( hl� .... ::w.,� s�c^�xe,.,.!2��1 �.axx y.�tl Ltt - � ;.:,� .£F. �.a;;:'
Please remi payments only to the following a dress:
enry Schein, Inc.
ept CH 102 1
Palatine, I 60055-0241
LH ILL T.0 SHIP TO INV ICE INVOICE AMOUNT ITEM STATUS KEY 7REM KEY
0 8 5 71 181710 2 8 2 9 8 613-0 2 9 9 .5 0 H Backordered:ucm will follow chool Kit D-Discontinued:Item no longer available No Charge
P Special Schein Free Goods
�� R DER ORDER ATE INVOICE DATE 4 OF BOXES M-Manufacturer will ship Item directly to you
P-Prescription Drug:Return Authorization Required
12235391 08/28/13 8/3 0/13 ]
R -Refrigerated Item:May be shipped separately
C T MER Pb4 PAGE $ -Special Schein Pricing
T-Taxable Item
U-Temporarily unavailable:please reorder
MARK 2 OF 2 Rem has MSDS
LP300
......... ......... ......... ....... ......... ..... . . .. .. ......... .--.... ._...........
..... ......... ....._... __._. ...... ......... ........... ........ .. ......... ......... ......... ... ..._ ..... .. ..........
HENRY Imo`
EMS
......... .... ..... ..... .... .........
......... ......... ...._._.. _._._ ........... ...... ......... ......... .................... ......... ......_...........................
.,`V'e make very`r ff,rt i„ ainfain prices`:,r the duratinn,;f a Payment by CHECK or by the HENRY`"SCHEIN CREOIT CARD,
ata o,however,we reserve the right to make price adjustments VISA,MASTERCARD,DISCOVER and AMERICAN EXPRESS
response to manufacturers`price l-ianges
Guaranteed Satisfaction, vfsn
or
If ycu'have tied a oroduct and it is defecfive or does not oerforn Bill �r
�t€s`a 'orilY: �,,e 4��ill urcmde a credit,refund,or exchange;it ;Dirt
e r6
yr�e r: t. :,x-: ,ai'ab e to licensed practif.t?r ors i t.w U.S.A1....rvoi es are
choice, inVv pall our customer service de,;art:y:en:-Y hin�'0 days a <b r ;rithin;? days,
of r,c=i^t^t fti rrierc:a.-dise to arrange:for the return. Fora � '
warrant,-Y:''erialr or it vo::were sen°somolfi Ig you did n;t ureter,
dimply call: Px Products €stroll d Substances:
latrx Medical 1-800-845-3550
Regulations require€;s to limit the sale of P x and c=ontr lk d
substances only to registered,Been ed healthcare professionals.
If you are a new customer or have recently moved,please fUMish
us with.a copy of tour updated s°ate reg stratlon. For Controlled
substances,f irni h a copy of±four DEAD certificate,verifyir q your
shipping address, Class Il drt(.;s can be ordered only ib �m:ail.
International Orders:
Pilease Notes
_..._...___...I.._.............
vv`e proudly servo healthcare r)rofassionals an!governments
Opened hand;feces and equipment may not be reLimed for �, - �,,. �
credit;bu`Kraal buy repaired or replaced in accordancr �.�,i h t roughout the,vorid, :�pace,;rd.�rs or f r r-quir es on export
terms and conait ons.olease contact our l n errlational ,epart€��ent:
f c,a el of '
manuf<<li: r��;rrantis�s.B �,rr;�p�fning handf.iEC;s or `-8CU-845-�,,v�u
equipment,vve s ggeQ—t that,Yc;u::hecK`,e s ,p?ng container
and packing list to+. ri'y t~af „you eye received.exactly what Prescription Drug Returns Instructions:
VU r erdered.Cpened Computer Software is not returnable.
Other restrictions may also apply.
A t9eturn;hut,orizat:on is Required for all Presuipikon"DrUgs.&r�ply call
our Euston er Service Depa rnent 1 X00-84
VOUCHER NO. WARRANT NO.
ALLOWED 20
Henry Schein
IN SUM OF $
Dept Ch 10241
Palatine, IL 60055
$99.50
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I 8298613-02 1 102-390.11 I $99.50 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
EP G 3'2013
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Drescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
4n invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
Nhom, 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))
8298613-02 $99.50
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