102164 FIREFIGHTER BEHAVIORAL HEALTH it'''.::.,166-
- °INDINA RETAIL TAX EXEMPT • Pae1f1C ,. �a� e]I CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
�. FEDERAL EXCISE TAX EXEMPT
102164
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
19128/20.18 372964
FIREFIGHTER BEHAVIORAL HEALTH ALLIA Common Council
VENDOR ,''365.5.W ANTHEM WAY SHIP 1 Civic Square
TO Carmel, IN 46032-
SUITE-A-109-374 ,
ANTHEM,AZ 85086- - _
PURCHASE ID:' =.BLANKET' I CONTRACT J PAYMENT TERMS FREIGHT
1360
{ QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE , EXTENSION
Department:.:; Fund::
Account -
Each .
. Sub Total
Department 1401 Fund 101 General Fund.
Account: `43 570.02
1 Each' takin it to the streets $4;900:00 $4,900.000
; :
Sub Total .. $4,900. 0
Send Invoice To t ',..�
Common Council'.
E
1 Civic Square
Carmel; IN 46032-
PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
PAYMENT $4,900:00
SHIPPING INSTRUCTIONS *NP VOUCHER CANNOT BE APPROVE D FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A
PART OF THE VOUCHER AND EVERY INVOICE AND-V• .HE' ASE SWORN
SHIP PREPAID AFFIDAVITATT Er I HERE:' CERTIFY THAT • AN U IsBLIGATED'BALANCE IN
AC
C 0 D SHIPMENT CANNOT BE ACCEPTED.." THIS AP OP: ION SUFFICIENT�PAY FO' OVE OR► R:
'PURCHASE ORDER NUMBER'MUST APPEAR.ON ALL SHIPPING LABEL_ "/ /
' 'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 7
'AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
ORDERED BY
TITLE '
CONTROL"NO. 102164 . CLERK-TREASURER