225401 10/23/2013 a CITY OF CARMEL, INDIANA VENDOR: 357526 Page 1 of 1
�f ONE CIVIC SQUARE HENRY SCHEIN INC CHECK AMOUNT: $1,419.32
? CARMEL, INDIANA 46032 DEPT CH 10241
«o� PALATINE IL 60055-0241 CHECK NUMBER: 225401
CHECK DATE: 10/23/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 4239011 5479249-01 402 . 96 SPECIAL DEPT SUPPLIES
102 4467006 5479249-01 1, 016 . 36 EMS EQUIP
13320851 10/09/13 11/08/139
ouo#o1-243'0880
*nsponA# RHO]62494 Fed ID: 11'3136595
This order -las been processed by our MIDWEST D.C.
5315 WES" 74TH 3TREET
ASE GOOD I 'EM, MAY BE SHIPPED SEPARATELY.
ASE GOOD IPEM, MAY BE SHIPPED SEPARATELY.
3 857-3847 EA NASAL AIRWAY LF 26FR 10 10 2.40 24.00 9
4 857-3190 EA NASAL AIRWAY LF 28FR 10 10 2.40 24.00 9
5 857-4186 EA NASAL AIRWAY LF 34FR 10 10 2.40 2400 9
6 499-6737 EA NON-REBREATHER MASK ADULT 100 100 C 0.90 90.00 6
--ASE GOOD ITEM, MAY BE SHIPPED SEPARATELY.
7 890-9048 200/BX WEBCOL ALCOHOL PREPS STERILE 40 40 *C 1.47 58.80 8
--ASE GOOD I—EM, MAY BE SHIPPED SEPARATELY.
8 220-1398 3/ST BODY STRAP SET DISP YELLOW 2 2 5.32 10.64 10
THIS PRODUCT IS BEING SHIPPED FROM OUR NORTHEAST DISTRIBUTION CENTER.
9 220-1398 3/ST BODY STRAP SET DISP YELLOW 98 98 5.32 521.36 9
THE PRICES TATED ABOVE MAY REFLECT A DISCOUNf OR BE SUBJE T TO A REBATE YOU
BILL TO SHIP TO INVOICE# INVOICE AMOUNT ITEM STATUS KEY
11308571 1 1817102 5479249-01 1419.32 1)-Discontomed:Item no longer available
F-Special Schein Free Goods
HSI ORDFRif [ RDER DATE INVOICE DATE # OF BOXES M-Manufacturer will ship Item directly to you
13320851 10/09/13 10/09/13 10 R Refrigerated Item:Mauy be suipped separately
$ Special Schein Pricing
U-Temporarily unavailable:please reorder
HMARK 1 OF 2 Item has NISDS Continued on Next Page..........
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R HENRY SCHEIN,#)
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
010000130857105479249110010000001,419321009137 BILL TO:
Carmel Fire Dept MI
2 Civic Sq
Carmel, IN 46032-7543
Carmel Fire Dept GILL To I SHIP TO INVOICE AMOUNT
2 Civic Sq
Carmel, IN 46032-7543 1308571 1817102 1419 .32
INVOICE# INVOICE DATE
5479249-01 10/09/13
CUSTOMER PO
� MARK
I_ Please detach here and mail the above with your payment
HSI ORDER# I ORDER DATE IQUE DATE
13320851 10/09/13 11/08/13
D&B#:01-243-0880
WHSE DEA# RHO162494 Fed ID: 11-3136595
� ^-•? ' °� - tt`• y, ,�''°`>z•;Via,,° m ,.�
c • R a s .•r. •wad';-2-� :,��'.--:,,'r.• s e t l . 8•%,; g:;%. _ ,y • 1e4.
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 PROGRAM UPON REQUESI BY ANY SUCH FROGRAM.
IT ISYOUR ZESPONSIBILITY TO REVIEW ANY AGREEMENTS OZ OTHEF DOCUMENTS AP LICABLE
TO THESE P ICES TO DETERMINE IF THEY ARE SUBJECT TO A REB TE. THE FEDERAL
OVERNMENTI 4POSES CERTAIN RESTRICTIONS ON, AND REQUI ZES PU LIC REPORTING OF,
RANSFERS O VALUE TO A PRACTITIONER. IF YOU ARE PARTICIPATING IN A PROMOTIONAL
ISCOUNT PR GRAM (E.G. POINTS, DISCOUNT REDEM TIONS R OTHER SPECIAL AWA DS) ,
ITH YOUR P JRCHASES YOU MAY EARN POINTS/CREDI S REDE IMABLE FOR CERTAIN GOODS OR
ERVICES, 14 ACCORDANCE WITH DISCOUNT PROGRAM RULES. UPON EISCOUNT RECEIPT BY
EDEMPTION F YOUR EARNED POINTS/CREDITS, YOU ARE RE'EIVINC OR WILL RECEIVE
OTICE OF TIE DISCOUNT VALUE. ACCORDINGLY, YOJ SHOUL RETAIN THESE RECOR S.
ortheast D stribution Center
1 WEAVER R AD
DENVER, PA 17517____________________________
MERCHANDI E TOTAL 1419.32
Invoice Date + 30 days 1419.32
lease remi payments only to the following a dress:
Henry Schei , Inc.
Dept CH 102 1
Palatine, IL 60055-0241
BIT,L TO SHIP TO INVOICE4 INVOICE AMOUNT ITEM STATUS KEY REM KEY
1308571 1817102 5479249-01 1419 .3 2 B-Backordered:Item will follow
D-Discon inued:Item no long
er available NC--SNo h oCharge
H I RDER 1. Special Free Goods t
ORDER DATE INVOICE DATE 4 OF M-Manufacturer will ship Item directly to you
P-Prescription Drug:Return Authorization Required
13320851 10/09/13 10/09/13 10 R-Refrigerated Item:May be shipped separately
CUSTOMER PO# PAGE $ -Special Schein Pricing
T-Taxable Item
U-Temporanly unavailable:please reorder
MARK 2 OF 2 * -uem has ntSDs
------------------ ................
f I° 9 HENRY SCHEIN`"'
EMS ," E- M` A
- ------------.......................
Payinent
We make every effort to maintain prices for the duration of a Payment by CHECK or by the HENRY SCHEIN CREDIT CARD,
catalog,however,we reserve the right to make price adjustments in
VISA,MASTERCARD,DISCOVER and AMERICAN EXPRESS
response to manufacturers'price changes
F7---J
Guaranteed Satisfaction:
If you have tried a product and it is defective or does not perform or
satisfactorily,we will provide a credit,refund,or exchange;it's your 1301 Your Order To Your Open Account
choice, Simply call our customer service department within 30 days Available to licensed practitioners in the U.S.All invoices are
payable within 30 days.
of receipt of the merchandise to arrange for the return. For a
warranty repair or it you were sent something you did not order,
simply call: Rx Products & Controlled Substances:
Matrx Medical 1-800-845-3550
Regulations require us to limit the sale of Rx and controlled
substances only to registered,licensed healthcare professionals.
If you are a new customer or have recently moved,please furnish
us with a copy of your updated state registration. For controlled
substances,furnish a copy of your DEA certificate,verifying your
shipping address. Class 11 drugs can be ordered only by mail.
International Orders:
Please Note:
Opened handpieces and equipment may not be returned for we serve healthcare professionals and governments
credit.but will be repaired or replaced in accordance with throughout the world. To place orders or for inquiries on export
manufacturer.facturer warranties,Before opening handpieces or terms and conditions,please contact our International Department:
1-800-845-3
equipment,we suggest that you check the shipping container 5550
and packing list to verity that you have received exactly what
you ordered.Opened Computer Software is not returnable. Prescription Drug Returns Instructions:
Other restrictions may also apply. A Return Authorization is Required for all Prescription Drugs.Simply call
our Customer Service Department @ 1-800-845-3550,
7 -7 77 T 7,7
,mc "Dll
. 0
LP300
arescribed 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
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))
5479249-01 $1,016.36
5479249-01 $402.96
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
$1,419.32
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 5479249-01 102-670.06 $1,016.36 1 hereby certify that the attached invoice(s), or
1120 5479249-01 102-390.11 $402.96 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 OCT 2 12013
' A,�� P,
m
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund