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ATTACHMENT 4 <br /> FORM STATE OF WASHINGTON �s F' AGENCYUSE ®NL$7 . <br /> A19-1A Coi�ITRACT NovOiCall3TFrkpd <br /> INVOICE VOUCHER 103 <br /> oAGENGY NAME S -,z ;;' 4AiStA CT NS TQ UEisibb OkftgA Nj l tt " <br /> Department of Community,Trade&Economic Development In the absence of a detailed invoice,submit this form to claim payment for <br /> Office of Archaeology&Historic Preservation materials,merchandise or services. Show complete detail for each item. <br /> 1063 South Capital Way Suite 106 PO Box 48343 <br /> Olympia,Wa 98504-8343 Vendor's Certificate: <br /> I hereby certify under penalty of perjury that the items and totals listed herein <br /> ATTN: are proper charges for materials,merchandise or services furnished to the <br /> VENDOR OR'OMNI nrarian is tosbe sa able tTo n goods furnished and/or services rendered have <br /> � � � P � � State of Washington,and that all <br /> been provided without discrimination because of age,sex,marital status,race, <br /> City of Everett creed,color,national origin,handicap,religion,or Vietnam era or disabled <br /> 2930 Wetmore Avenue, Suite 8A veteran status. <br /> Everett, WA 98201 <br /> By: <br /> (Sign in ink) <br /> (Title) (Date) <br /> FEDERAL I.D.NO.OR SOCIAL SECURITY NO. RECEIVED BY DATE RECEIVED <br /> 91-0983680 <br /> q11:4,11, tkolt ism ti s iegmv7-40;c737,tot to or isto 71,4•,74: 'IA 14 Wyk. 10,04, <br /> • <br /> PREPARED BY(Fiscal) DATE DIVISION APPROVAL DATE <br /> DOC DATE CURRENT DOC NO REF DOC NO VENDOR NUMBER VENDOR MESSAGE <br /> M SUB <br /> TRANS 0 APPN PROGRAM SUB SUB INVOICE GENERAL <br /> SUF CODE D FUND INDEX INDEX OBJ OBJ CNTY CITY PROJECT AMOUNT NUMBER LEDGER <br /> APPROVED FOR PAYMENT BY FISCAL DATE WARRANT TOTAL <br /> 32 <br /> Approved CTED Form A19-1A (10/15/95) <br />