227332 12/17/2013 CITY OF CARMEL, INDIANA VENDOR: 366017 Page 1 of 1
ONE CIVIC SQUARE ENVIROCERT INTERNATIONAL,INC
CARMEL, INDIANA 46032 49 STATE STREET CHECK AMOUNT: $100.00
MARION NC 28752 CHECK NUMBER: 227332
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CHECK DATE: 12117/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
211 4462838 THOMAS 100 . 00 STORM WATER PHASE II
PROFESS/°29`
CPESC Renewal Notice m �(--�-®
°s CPESC o�
2013 - 2014 °"ANOSED,M0
JOHN GHARRITY THOMAS Amount Due: $100.00
11576 CREEK SIDE LANE Date Due: December 31, 2013
CARM EL, IN 46033 RETURN THIS FORM WITH YOUR PAYMENT
Renewal Fee Details:
-CP-FSC#_3668...:........:.:4nnua!_Rate:-$100.00..:.::........Yezrs:1—............Amount Due:-$1JO:J O...........................Status:-Active --
Professional Development Affirmation:
Current Period: 12/31/2011-12/30/2014.......................Requirement: 60 PDUs per 3 Year Period- Minimum of 2 Categories
Due Date for PDUs: 12/31/2014
Review your training records and select either YES or NO in response to the following statement:
I HAVE COMPLETED PROFESSIONAL DEVELOPMENT REQUIREMENTS FOR THE CURRENT PERIOD: ❑ YES $ NO
Sign and date in the space below. (See back page for explanation.)
John Gharrity Thomas Date
Information Update: (Please mark this notice with any changes to your contact information.)
Business Phone: (317)571-2314
Ext.
Fax: (317)571-2439
Home Phone: (317)815-1196
Email: jthomas @carmel.in.gov
Please list any professional titles that you currently-hold (for example, PE, RLA): —
Payment Information
ENTER YOUR PAYMENT INFORMATION ON THE REVERSE SIDE OF THIS NOTICE.
49 STATE STREET MARION, NC 28752 PHONE: 828.655.1600 FAX: 828.655.1622 WWW.CPESC.ORG
THE CPESC CERTIFICATION PROGRAM IS A DIVISION OF ENVIROCERT INTERNATIONAL,INC.
John Gharrity Thomas FCPESC # 3668
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11576 Creek Side Lane _� r
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Cmel„`IN,46033<?” ,
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Payment Information (Please write legibly)
RETURN THIS SHEET WITH YOUR PAYMENT.
Payment amount: loo'00 (in US dollars)
Payment method: ]Check/Money Order ❑Visa ❑American Express ❑ MasterCard ❑ Discover
Make check payable to EnviroCert International, Inc. in US funds.
Credit Card Number: - - -
Expiration Date: m / m Card Security Code: _ _.
Name of Card Holder
Signature of Card Holder
Address of Card Holder
IMPORTANT! Check the reverse side of this form to ensure that the Professional Development
Affirmation section has been signed and dated.
Professional Development Affirmation Explanation
Professional development is a fundamental component of the CPESC program. To complete renewal, you must
sign the affirmation statement(on the reverse side of this notice)regarding your compliance with professional
development requirements. Failure to renew your certification by paying the renewal fee AND signing the
affirmation statement is a basis for suspension of your certification.
Checking YES means that you have completed the PDU requirements for the current period. We will advance your
PDU period to the next three-year block and issue a new ID card.
Checking NO means that you have NOT completed the requirements for the current PDU period. Your CPESC
certification will remain Active and a new ID card will be issued. However,we will NOT advance your PDU period
to the next three-year block.
If you need assistance in determining whether you have met the PDU requirements, please contact our office as
shown on the reverse side of this notice. Remember, it is a violation of the Code of Ethics to knowingly provide
false information to the CPESC Administrative Office. (See CPESC Certification Procedures and Standards,Article II,
Section 4, Item B.2 for details.)
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
EnviroCert International Purchase Order No.
49 State Street Terms
Marion, NC 28752 Date Due
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s) Amount
1/0/1900 0 CPESC Renewal $ 100.00
3
Total $ 100.00
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 NC WARRANT NO.
EnviroCert International ALLOWED 20
49 State Street IN SUM OF $
Marion, NC 28752
$ 100.00
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITL AMOUNT
DEPT# I hereby certify that the attached invoice(s),
0 0 211-4462838 $ 100.00 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
12/16/2013
Signature
City Engineer
Cost Distribution ledger classification if Title
claim paid motor vehicle highway fund