31870 Worksafe A INDIANA RETAIL TAX EXEMPT
PAGE
,.r 7.o i C a ir e l `CBTFCA L NO.003120155 002 0
PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 31870
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,VP
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
4/14/2014
WorkSafe USA, Inc. Street Department
VENDOR SHIP 3400 W. 131st Street
TO
326 Hopple Hills Dr. Carmel, IN 46074
Springfield, IL 62707 (317) 733-2001
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 2201-670.99
1 Each Dump-Lok Safety Device System $1,085.48 $1,085.48
Sub Total: $1,085.48
if 7
ItT,
Send Invoice To: _i -2 ' °" �
1
Street Department
3400 W. 131st Street .
Carmel, IN 46074-
PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Carmel Street Department PAYMENT $1,085.48
• NP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE PO.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS • I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIATION SUFFJCIENT O PAY FOR THE ABOVE ORDER.
•SHIP REPAID. //AP APPROPRIATION AT I)
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED.
• PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY j
SHIPPING LABELS ���, n�- r 'k4 / SS ,�K Q e
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE `.J ft n D'
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
DOCUMENT CONTROL NO. 31870 CLERK-TREASURER
A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE