David Moore/Fire/6,775/FEMA Requirement InstructionDavid Moore
Fire Department - 2017 Cko`�Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00 JqQ
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES
THIS AGREEMENT FOR PURCHASE OF GOODS AND SERVICES ("Agreement") is hereby entered into by
and between the City of Carmel, Indiana, acting by and through its Board of Public Works and Safety ("City"), and
David Moore, an entity duly authorized to do business in the State of Indiana ("Vendor").
TERMS AND CONDITIONS
ACKNOWLEDGMENT, ACCEPTANCE:
Vendor acknowledges that it has read and understands this Agreement, and agrees that its execution of
same constitutes its acceptance of all of the Agreement's terms and conditions.
PERFORMANCE:
City agrees to purchase the goods and/or services (the "Goods and Services") from Vendor using City
budget appropriation number 43-570.03 funds. Vendor agrees to provide the Goods and Services and to
otherwise perform the requirements of this Agreement by applying at all times the highest technical and
industry standards. Vendor will not perform any of the Services detailed in Exhibit A prior to obtaining a
written Notice to Proceed from the City. Upon receiving a Notice to Proceed, the Vender shall perform only
those Services specifically detailed in the Notice. If the Vender desires clarification of the scope of any
Notice to Proceed, the Vendor shall obtain such clarification from the City in writing, prior to performing the
service set forth in the Notice to Proceed. Any services performed without the City's prior express written
authorization will not be compensated.
3. PRICE AND PAYMENT TERMS:
3.1 Vendor estimates that the total price for the Goods and Services to be provided to City hereunder
shall be no more than Six Thousand Seven Hundred Seventy Five Dollars ($6,775.00) (the
"Estimate"). Vendor shall submit an invoice to City no more than once every thirty (30) days detailing
the Goods and Services provided to City within such time period. City shall pay Vendor for such
Goods and Services within thirty-five (35) days after the date of City's receipt of Vendor's invoice
detailing same, so long as and to the extent such Goods and Services are not disputed, are in
conformance with the specifications set forth in Exhibit A, are submitted on an invoice that contains
the information contained on attached Exhibit B, and Vendor has otherwise performed and satisfied
all the terms and conditions of this Agreement.
3.2 Vendor agrees not to provide any Goods and Services to City that would cause the total cost of the
Goods and Services provided by Vendor to City hereunder to exceed the Estimate, unless City has
previously agreed, in writing, to pay an amount in excess thereof.
4. WARRANTY:
Vendor expressly warrants that the Goods and Services covered by this Agreement will conform to those
certain specifications, descriptions and/or quotations regarding same as were provided to Vendor by City
and/or by Vendor to and accepted by City, all of which documents are incorporated herein by reference, and
that the Goods and Services will be delivered in a timely, good and workmanlike manner and free from
defect. Vendor acknowledges that it knows of City's intended use and expressly warrants that the Goods and
Services provided to City pursuant to this Agreement have been selected by Vendor based upon City's
stated use and are fit and sufficient for their particular purpose.
IXACwtrscts\Pmf.Sv & G -d S—Tim Dep1\20 MD -id Mc Gads end S—icesA-91272017 11:56 AMI
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
TIME AND PERFORMANCE:
This Agreement shall become effective as of the last date on which a party hereto executes same ("Effective
Date"), and both parties shall thereafter perform their obligations hereunder in a timely manner. Time is of the
essence of this Agreement.
6. DISCLOSURE AND WARNINGS:
If requested by City, Vendor shall promptly furnish to City, in such form and detail as City may direct, a list of
all chemicals, materials, substances and items used in or during the provision of the Goods and Services
provided hereunder, including the quantity, quality and concentration thereof and any other information
relating thereto. At the time of the delivery of the Goods and Services provided hereunder, Vendor agrees to
furnish to City sufficient written warning and notice (including appropriate labels on containers and packing)
of any hazardous material utilized in or that is a part of the Goods and Services.
7. DEFAULT:
In the event Vendor: (a) repudiates, breaches or defaults under any of the terms or conditions of this
Agreement, including Vendor's warranties; (b) fails to provide the Goods and Services as specified herein;
(c) fails to make progress so as to endanger timely and proper provision of the Goods and Services and does
not correct such failure or breach within five (5) business days (or such shorter period of time as is
commercially reasonable under the circumstances) after receipt of notice from City specifying such failure or
breach; or (d) becomes insolvent, is placed into receivership, makes a general assignment for the benefit of
creditors or dissolves, each such event constituting an event of default hereunder, City shall have the right to
(1) terminate all or any parts of this Agreement, without liability to Vendor; and (2) exercise all other rights
and remedies available to City at law and/or in equity.
INDEMNIFICATION:
Vendor agrees to indemnify, defend and hold harmless City and its officers, officials, agents and employees
from all claims and suits of whatever type, including, but not limited to, all court costs, attorney fees, and
other expenses, caused by any act or omission of Vendor and/or of any of Vendor's agents, officers,
employees, contractors or subcontractors in the performance of this Agreement. These indemnification
obligations shall survive the termination of this Agreement.
9. GOVERNMENT COMPLIANCE:
Vendor agrees to comply with all federal, state and local laws, executive orders, rules, regulations and codes
which may be applicable to Vendor's performance of its obligations under this Agreement, and all relevant
provisions thereof are incorporated herein by this reference. Vendor agrees to indemnify and hold harmless
City from any loss, damage and/or liability resulting from any such violation of such laws, orders, rules,
regulations and codes. This indemnification obligation shall survive the termination of this Agreement.
10. NONDISCRIMINATION:
Vendor represents and warrants that it and all of its officers, employees, agents, contractors and
subcontractors shall comply with all laws of the United States, the State of Indiana and City prohibiting
discrimination against any employee, applicant for employment or other person in the provision of any Goods
and Services provided by this Agreement with respect to their hire, tenure, terms, conditions and privileges of
employment and any other matter related to their employment or subcontracting, because of race, religion,
color, sex, handicap, national origin, ancestry, age, disabled veteran status and/or Vietnam era veteran
status.
IXACon�ysTroLS-s & Goods S—Tire De[t120170svid Maze Goals end S—icesA-91272017 11:56+ AM]
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
11. E -VERIFY:
Pursuant to I.C. § 22-5-1.7 et seq., as the same may be amended from time to time, and as is incorporated
herein by this reference (the "Indiana E -Verify Law"), Vendor is required to enroll in and verify the work
eligibility status of its newly -hired employees using the E -Verify program, and to execute the Affidavit
attached herein as Exhibit C, affirming that it is enrolled and participating in the E -verify program and does
not knowingly employ unauthorized aliens. In support of the Affidavit, Vendor shall provide the City with
documentation indicating that it has enrolled and is participating in the E -Verify program. Should
Vendor subcontract for the performance of any work under and pursuant to this Agreement, it shall fully
comply with the Indiana E -Verify Law as regards each such subcontractor. Should the Vendor or any
subcontractor violate the Indiana E -Verify law, the City may require a cure of such violation and thereafter, if
no timely cure is performed, terminate this Agreement in accordance with either the provisions hereof or
those set forth in the Indiana E -Verify Law. The requirements of this paragraph shall not apply should the E -
Verify program cease to exist.
12. NO IMPLIED WAIVER:
The failure of either party to require performance by the other of any provision of this Agreement shall not
affect the right of such parry to require such performance at any time thereafter, nor shall the waiver by any
party of a breach of any provision of this Agreement constitute a waiver of any succeeding breach of the
same or any other provision hereof.
13. NON -ASSIGNMENT:
Vendor shall not assign or pledge this Agreement, whether as collateral for a loan or otherwise, and shall not
delegate its obligations under this Agreement without City's prior written consent.
14. RELATIONSHIP OF PARTIES:
The relationship of the parties hereto shall be as provided for in this Agreement, and neither Vendor nor any
of its officers, employees, contractors, subcontractors and agents are employees of City. The contract price
set forth herein shall be the full and maximum compensation and monies required of City to be paid to
Vendor under or pursuant to this Agreement
15. GOVERNING LAW; LAWSUITS:
This Agreement is to be construed in accordance with and governed by the laws of the State of Indiana,
except for its conflict of laws provisions. The parties agree that, in the event a lawsuit is filed hereunder, they
waive their right to a jury trial, agree to file any such lawsuit in an appropriate court in Hamilton County,
Indiana only, and agree that such court is the appropriate venue for and has jurisdiction over same.
16. SEVERABILITY:
If any term of this Agreement is invalid or unenforceable under any statute, regulation, ordinance, executive
order or other rule of law, such term shall be deemed reformed or deleted, but only to the extent necessary to
comply with same, and the remaining provisions of this Agreement shall remain in full force and effect.
[XXonVw1s\Prof.Svcs & Goods S—Tire De0t\20171David Moore Goods and Servi—d-9127/2017 11:56 AMI
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
17. NOTICE:
Any notice provided for in this Agreement will be sufficient if it is in writing and is delivered by postage
prepaid U.S. certified mail, return receipt requested, to the party to be notified at the address specified
herein:
If to City: Carmel Fire Department
Two Civic Square
Carmel, Indiana 46032
If to Vendor: David Moore
2735 N Riley Highway
Shelbyville, IN 46176
AND Douglas C. Haney,
Corporation Counsel
Department of Law
One Civic Square
Carmel, Indiana 46032
Notwithstanding the above, notice of termination under paragraph 18 hereinbelow shall be effective if given
orally, as long as written notice is then provided as set forth hereinabove within five (5) business days from
the date of such oral notice.
18. TERMINATION:
18.1 Notwithstanding anything to the contrary contained in this Agreement, City may, upon notice to
Vendor, immediately terminate this Agreement for cause, in the event of a default hereunder by
Vendor and/or if sufficient funds are not appropriated or encumbered to pay for the Goods and
Services to be provided hereunder. In the event of such termination, Vendor shall be entitled to
receive only payment for the undisputed invoice amount representing conforming Goods and
Services delivered as of the date of termination, except that such payment amount shall not exceed
the Estimate amount in effect at the time of termination, unless the parties have previously agreed in
writing to a greater amount.
18.2 City may terminate this Agreement at any time upon thirty (30) days prior notice to Vendor. In the
event of such termination, Vendor shall be entitled to receive only payment for the undisputed
invoice amount of conforming Goods and Services delivered as of the date of termination, except
that such payment amount shall not exceed the Estimate amount in effect at the time of termination,
unless the parties have previously agreed in writing to a greater amount.
18.3 The City may terminate this Agreement pursuant to Paragraph 10 hereof, as appropriate.
19. REPRESENTATIONS AND WARRANTIES
The parties represent and warrant that they are authorized to enter into this Agreement and that the persons
executing this Agreement have the authority to bind the party which they represent.
20. ADDITIONAL GOODS AND SERVICES
Vendor understands and agrees that City may, from time to time, request Vendor to provide additional goods
and services to City. When City desires additional goods and services from Vendor, the City shall notify
Vendor of such additional goods and services desired, as well as the time frame in which same are to be
provided. Only after City has approved Vendor's time and cost estimate for the provision of such additional
goods and services, has encumbered sufficient monies to pay for same, and has authorized Vendor, in
writing, to provide such additional goods and services, shall such goods and services be provided by Vendor
to City. A copy of the City's authorization documents for the purchase of additional goods and services shall
be numbered and attached hereto in the order in which they are approved by City.
[XACmo aclsTrn(.S— & Gm s Svcs\Fire Dep1120170avid Mmre G-1., and S—iccsA-9/27/2017 11:56 AMI
4
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
21. TERM
Unless otherwise terminated in accordance with the termination provisions set forth in Paragraph 18
hereinabove, this Agreement shall be in effect from the Effective Date through December 31, 2017 and shall,
on the first day of each January thereafter, automatically renew for a period of one (1) calendar year, unless
otherwise agreed by the parties hereto.
22. HEADINGS
All heading and sections of this Agreement are inserted for convenience only and do not form a part of this
Agreement nor limit, expand or otherwise alter the meaning of any provision hereof.
23. BINDING EFFECT
The parties, and their respective officers, officials, agents, partners, successors, assigns and legal
representatives, are bound to the other with respect to all of the covenants, terms, warranties and obligations
set forth in Agreement.
24. NO THIRD PARTY BENEFICIARIES
This Agreement gives no rights or benefits to anyone other than City and Vendor.
25. IRAN CERTIFICATION:
Pursuant to I.C. § 5-22-16.5, the Vendor shall certify that, in signing this document, it does not engage in
investment activities within the Country of Iran.
26. ADVICE OF COUNSEL:
The parties warrant that they have read this Agreement and understand it, have had the opportunity to obtain
legal advice and assistance of counsel throughout the negotiation of this Agreement, and enter into same
freely, voluntarily, and without any duress, undue influence or coercion.
27. ENTIRE AGREEMENT:
This Agreement, together with any exhibits attached hereto or referenced herein, constitutes the entire
agreement between Vendor and City with respect to the subject matter hereof, and supersedes all prior oral
or written representations and agreements regarding same. Notwithstanding any other term or condition set
forth herein, but subject to paragraph 16 hereof, to the extent any term or condition contained in any exhibit
attached to this Agreement or in any document referenced herein conflicts with any term or condition
contained in this Agreement, the term or condition contained in this Agreement shall govern and prevail.
This Agreement may only be modified by written amendment executed by both parties hereto, or their
successors in interest.
[XAContracts\Prof.S— & Goods S—Tire Dgn\20170-id Moorc Goods and SmicaA-9R7R017 11:56 AMI
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA David Moore
by and through its Board of Public
Works and Safety
By: By:
James Brainard, Presiding Officer Authorized Signature
Date:
Mary Ann Burke, Member
Date:
Lori S. Watson, Member
Date:
ATTEST:
Christine S. Pauley, Clerk -Treasurer
Date:
1XAConoaals\Prof.Svcs & Goads S—Tire Dgn120170avid Ma C .di and Savior doc:9R7R017 11:56 AM]
Printed Name
Title
FID/TIN:
Last Four of SSN if Sole Proprietor:
Date:
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
EXHIBIT B
Invoice
Name of Company:
Address & Zip:
Telephone No.:
Fax No.:
Project Name:
Invoice No.
Purchase Order No:
Date:
Signature
Printed Name
jXACmmnasWrof.Sva & Goods S—Tire Dep\20171David Moore Goals and Savi—d-9272017 11:56 AK
Goods
Services
Person Providing
Goods/Services
Date
Goods/
Service
Provided
Goods/Services Provided
(Describe each good/service
separately and in detail)
Cost Per
Item
Hourly
Rate/
Hours
Worked
Total
GRAND TOTAL
Signature
Printed Name
jXACmmnasWrof.Sva & Goods S—Tire Dep\20171David Moore Goals and Savi—d-9272017 11:56 AK
David Moore
Engineering Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
By:
41(�41 �-
James Brainard, Presiding Officer
MAry Annurke, ME
Date:
Lori S. t�Watso er
Date: f 10
AT T.
G1+
Christine S. P , ey, Clerk -T
Date:
JC:\Users\jonalhan_ab—thy\Do—loads\David Moom Goods and Savi—doc:8/28/2017 8:42 PMS
6
David Moore
7��
Authorized Signature
' ba (I , - / /) y- Ax te
Printed Name
Title
FID/TIN:
Last Four of SSN if Sole Proprietor: l�i
Date:
31 July 2017
To: Captain Steven Frye
From: David Moore, Ryan Rowley, Edward Moore, Jeff Cheshire
Reference: Quote for Carmel Fire Department FEMA Assistance to Firefighters Grant
Good afternoon Captain Frye
Below you will find a quote from a group of dedicated firefighters and instructors that can fulfill nearly
all the requirements for the courses offered. The only course we can't instruct right now is the Fire
Officer IV, however it is anticipated that by the start of the Fire Officer IV course we will have enough
instructors and proctors to instruct that course also.
The schedule will be set prior to the start of class. With the rotation of shift personnel, the schedule
may include a practical evaluation being completed prior to completion of instruction. However,
material for the practical evaluation will be covered prior to the practical evaluation
We propose the below Lead Instructor, Lead Evaluator & Adjunct Evaluator & test proctor. Most of the
courses will require a lead evaluator and adjunct evaluator due to the number of JPR's and in-depth
evaluation of those JPR's. Particularly with Instructor II/III with which the state has advised of a
guaranteed audit. Hours invoiced will only be for hours of instruction/evaluation, understanding that
some of the evaluations will happen outside of the classroom. Our rate is $25.00 hour.
David Moore 3379-8907 317-339-5758 dmmoore27@yahoo.com
Jeff Cheshire 9171-3620 317-450-1620 jcheshire@speedwayin.gov
Ryan Rowley 5634-3201 317-987-8074 ryanrowley99@gmail.com
Edward (Ted) C. Moore III 2467-5319 317-538-8833 firejunk@sbcglobal.net
As with all proposals we can't foresee the future, with the possibility of the above being moved to a
different shift either by choice or betterment of their department we may substitute an
instructor/evaluator or change the positions of the individuals listed above. However, if there are any
changes to the instructors or evaluators we will notify you of those changes and those individuals will be
qualified to teach the course, prior to the start of the course.
We thank you for time and consideration in this matter.
Please feel free to contact myself
David M. Moore
317-339-5758
Dmmoore27@yahoo.com
'EXHIBIT •
Fire Officer 1
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 1 The Company Officer 1
Chapter 2 Organizational Structure
Chapter 3 Leadership and Supervision
Chapter 4 Human resources Management 1
Learning Activities
Day 2
Chapter 5 Communications
Chapter 6 Administrative Funcions
Chapter 7 Health and Safety Issue
Learning Activities
Day 3
Chapter 8 Company -Level Training
Chapter 9 Community Relations and Company -Level Fire Inspections
Chapter 10 Preincident Survey
Learning Activities
JPR's
Day 4
Chapter 11 Delivery of Emergency Services 1
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
With this course there is combination of Learning Activities and JPR's that will be done
simultaneously. This course also has 4 JPR's that will need to be completed outside the
classroom with data from the students home department.
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
•Fxr-r►err
2�
Instructor 1
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 1 The Instructor as a Professional
Chapter 2 Principles of Learning
Chapter 3 Instructional Planning
Learning Activities
Day 2
Chapter 4 Instructional Materials and Equipment
Chapter 5 Learning Environment
Learning Activities
Day 3
Chapter 6 Classroom Instruction
Chapter 7 Skills Based Training Beyond the Classroom
Learning Activities
JPR's
Day 4
Chapter 8 Testing and evaluation
Chapter 9 Records, Reports and Scheduling
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
/4
o -c
FOST (Fire Officer Strategy and Tactics)
Carmel Fire Department 2017/2018
Student Syllabus
Dav 1
Chapter 1 Orientation and NIMS
Chapter 2 Fire Behavior
Chapter 3 Building Construction
Dav 2
Chapter 9 Water Supply
Chapter 4 Communications and the SizeUp Process
Chapter 5 Risk Management
Simulations
Day 3
Chapter 6 Rescue
Chapter 7 Ventilation
Chapter 8 Confinement, Extinguishment and Exposure Protection Considerations
Simulations/JPR's
Day 4
JPR's
Day 5
Morning- Completion of JPR's, Study session
Afternoon- Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted* M
"IXHIBIT
1 �
r(�
Fire Officer II
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 12 The Company Officer II
Chapter 13 Human Resources Management II
Learning Activities
JPR's
Day 2
Chapter 14 Administrative Responsibilities
Chapter 15 Origin and Cause Determination
Learning Activities
JPR's
Day 3
Chapter 16 Delivery of Emergency Services II
Chapter 17 Safety Investigations and Analysis
Learning Activities
JPR's
Day 4
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
"EXHIBIT ■
M/
Fire Officer III
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 2 Communications
Chapter 3 Personal and Professional Development
Chapter 4 Working in the Community
Chapter 5 Intergovernmental Relations
Learning Activities
JPR's
Day 2
Chapter 6 Human Resources
Chapter 7 Legal Issue
Chapter 8 Strategic Planning
Chapter 9 Emergency Management
Learning Activities
JPR's
Day 3
Chapter 10 Code Enforcement and Public Education
Chapter 11 Budget and Finance Issues
Learning Activities
JPR's
Day 4
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
"EXHIBIT
6��
Incident Safety Officer
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 1
Identify Safety Issues
Chapter 2
Risk Management
Chapter 3
Accident Review
Chapter 4
NFIRS
Learning Activities
JPR's
Day 2
Chapter 5 OSHA
Chapter 6 Investigative Report (HSO)
Chapter 7 Risk Management (HSO)
Chapter 8 Duties of HSO
Learning Activities
JPR's
Day 3
Chapter 9 HSO Maintenance
Chapter 10 Safety Areas of Concern
Chapter 11 Systems Based Changes
Learning Activities
JPR's
Day 4
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
"EXHIBIT
7wg
Instructor II/III
Carmel Fire Department 2017/2018
Student Syllabus
Day 1
Introduction
Chapter 10 Lesson Plan
Chapter 11 Training Evalutation
Chapter 12 Test Item Construction
Learning Activities
JPR's
Day 2
Chapter 13 Supervisory and Administrative Duties
Chapter 14 Instructor and classroom evaluations
Chapter 15 Course and Curriculum Development
Learning Activities
JPR's
Day 3
Chapter 16 Training Program Evaluation
Chapter 17 Training Program Administration
Learning Activities
JPR's
Day 4
JPR's
Day 5
Morning Finish JPR's/Study Session
Afternoon Written test (Online)
*Syllabus may be adjusted as class progresses, however all material will be covered in
the time allotted*
"EXHIBIT
David Moore
Fire Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
EXHIBIT B
Invoice
Name of Company:
Address & Zip:
Telephone No.:
Fax No.:
Project Name:
Invoice No.
Purchase Order No:
Date:
Signature
Printed Name
iSVonM as%Prol.Svcs & Goods S-sVve DepO20170avid Macre Goods and Servic doa:W7/2017 11:43 AM]
Goods
Services
Person Providing
Goods/Services
Date
Goods/
Service
Provided
Goods/Services Provided
(Describe each good/service
separately and in detail)
Cost Per
Item
Hourly
Rate/
Hours
Worked
Total
GRAND TOTAL
Signature
Printed Name
iSVonM as%Prol.Svcs & Goods S-sVve DepO20170avid Macre Goods and Servic doa:W7/2017 11:43 AM]
David Moore
Engineering Department - 2017
Appropriation # 43-570.03, P.O. #: 100682
Contract Not To Exceed $6,775.00
EXHIBIT C
AFFIDAVIT
M /
A0 d "r-- , being first duly sworn, deposes and says that
he/she is familiar with and has personal knowledge of the facts herein and, if called as a witness in this
matter, could testify as follows:
1.
01
3.
I am over eighteen (18) years of age and am competent to testify to the facts contained
herein.
I mi ow I at lj tirpps relevant herein have been employed by
a �K /K (the "Employer")
in the position of . - h 5
I am familiar with the employment policies, practices, and procedures of the Employer and
have the authority to act on behalf of the Employer.
4. The Employer is enrolled and participates in the federal E -Verify program and has
provided documentation of such enrollment and participation to the City of Carmel,
Indiana.
5. The Company does not knowingly employ any unauthorized aliens.
FURTHER AFFIANT SAYETH NOT.
EXECUTED on the _day of S %.� , 20.
( .
Printed: D—ct-
I
certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
Printed: –D,,y
IC:\Uurs\jonalhan_abc=thy\Downloads0—d Moore Goods and SmicaAm 8/28/2017 8:42 PMJ
INDIANA RETAIL TAX EXEMPT Page 1 of 1
City ®f Carmel CERTIFICATE NO. 003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 100682
ONE CIVIC SQUARE 35-6000972 THIS NUMBER MUST APPEAR ON INVOICES, AIP
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
8/24/2017 371893 Instructor Fee for AFG Grant Classes
J
DAVID MOORE Fire Department
VENDOR 2735 N RILEY HIGHWAY SHIP 2 Civic Square
TO Carmel, IN 46032-
SHELBYVILLE, IN 46176 -
PURCHASE ID BLANKET CONTRACT PAYMENT TERMS FREIGHT
16413 --
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Department: 1120 Fund. 101 General Fund
Account: 43-570.03
1 Each Fire Officer 1 $1,375.00 $1,375.00
1 Each Fire Officer II $1,375.00 $1,375.00
1 Each FOST $1,275.00 $1,275.00
1 Each Instructor 1 $1,375.00 $1,375.00
1 Each ISO $1,375.00 $1,375.00
Sub Total $6,775.00
of Cqq F
2
NI
Send Invoice To:
Fire Department
2 Civic Square
Carmel, IN 46032-
/1yQ A�
PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
PAYMENT $6,775.00
SHIPPING INSTRUCTIONS A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A
PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN
SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
'C O.D SHIPMENT CANNOT BE ACCEPTED. THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
'PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABEL
'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 �„�����-V Cmc 01
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDERED BY
Denise Snyder James Crider
TITLE Budget & Accreditation Manager Administration
CONTROL N0. 100682 CLERK -TREASURER