Professional Documents
Culture Documents
$75
BC
PC
MO
Tracking Number
Application Fee
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Afacility' owner
.
ans on this epplicatlon must ha answered,
Failure to respond.to all questlins or to provide all required infonnatlun will resultin a delay of
the Facility Regist~o11; Applicsti~.n mu.!rt ba sjgna~~~~."~!i:ae~:Make cashiar's_c~~V
\money order payable ID theTexas Bumf'ufChlropractii: Eaamme~ t)
l;aclllty Name
lo~
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Fax No.
TelephoneNo.
County
City
1-
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I Telephone No.
City
Stale
Fax No.
E-mail Address
ZIP Code
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SIGNATURE REOUIREO.
Form 101
Ver. 0412012
Facility Questionnaire
CPMPLETE FACILITY DllESTIDNNA!RE. ATTACH ANY REOlllRED FORMS ANO NDTARIZECMUST BE ANSWERED}
Does this facility sha~j>ffice space or staff but maintain
functions; D Yes [if'No If yes. since what date?
(mm~/ym)
~/.
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.... ,
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;.
D Yes
"2- 1 I)
(inm/~~/yyyy)
'"'
{mm/dd/yyyy)
lic~nse number:
(mm/dd/yyyy)
irmve ~e name of all this facility'.s licansad DCs 11r empl11yees that sre nm owlllll'S/partners. Include.the days and hours workedat the facility of
licensed DCs or em lo ees. Attach a se arate Form 101LD.for additional DCs or em lo ees.
License No.
Last
0{.~t>z..,
Days work@d at this.location
..
M. 0-J[JW~A-~0
License No.
M DTDWOTH
License No.
Name (first)
..---r-
,.,-W_
--TH
LasfName
Hours woi'ked al this location by day
D FD so
Name (first)
TH
TH
Last Name
M0T0W0TH0F0S0.
er SUBMIT AffiRM IDIA FDR EACH OWNER/PARTNER WITH AID% DR GREATER INlEREST IN THE FACILITY AND ATTACH TU THIS APPLICATION. FAILURE TU
ANSWER.All OUESTIDNS WILL DISaUAi.JFY YOUR FACILITY APPLICATION DR RENEWAL
OD() you.ow1:i;chiropi'actic f~cilitie's i!l arjoth!!r state(s)?
Yes [D1io
11 . ves. list the state(s) of Ucensure and 1our facility reoistralion number In the other states(s)
Statelsl Licensed
Facilitv Number
.StateCsl Licensed
Facllitv Ni.Jmber
8Have .you ever been the subject of a disciplinary action by the Texas Board of Chiropraciic Examiners or any other chiropraclic iicensing agency
and/or discJe!i_pery authority of another state? (Examples: Revocation, suspension of.license,. administrative.penalty. or letter. of.reprtmand.)
D Yes l.il'No
.11 you.answered yes, inc.rude the name of.the Board. llcenslng or disciplinary aultJorlty, the date of.the order, and If applicable, the date ofterminaUon of
the condition and/or.ore bl em.
Date of Order
Termination Date of Condition
Llcenslng/Dlsclpllnaiv Authorltv
Name of Board
.
eHave you ever been convicted of.' a felony or misdemeanor olherthan a traffic offense; but Including a drug or alcohol"relaled offense?
Yes llHJo
0Have you been subj of a deferred ad)udlcalion.for a felony or misdemeanor other than.a traflic offense, but including.a drug or alcoh.ol-ret1:1ted
offense? 0 Yes [ijoll\lo
If you answe~e~ Ye~ to Qu~sliori(s) 3 or 4, provide details on each conviction Including of!ense,.:punishment. dale. olconViction. whether you were
incarcerated, and if yoi.qire currently on probation or community supeivislon. To expedite your applicallon, you should notify the Board Immediately of
so lhal thev mav send.vouaddilional
materials
~or orocessrm
vour aoo11ca
r rion
anv.conviciion
reaulred
Incarcerated
Probation
Community
Conviction
PunishrtJent
Type of Offense
Date'
YestNo
YesJNo
Suoervislon
Fonn 19.~p2
Ver. 04/2012
Facility Notarization
State law prohibits renewing a license more than once after a licensee.has defaulted on .any
student or TGSLC loan. You should contact.your student loan institution or TGSLC before
completing this form. Texas Administrative Code 73.2, 80.2
Your license will not be renewed and suspended if information is received from the Attorney
General's Office, State of Texas that.the applicanfis in default of their Child Support Agreement per
FamilyCode, Chapter 22:.,Suspension of License, 232.003
Beforeme, the undersigned authority, on this day personally appeared the applicant whose
below, and who being by me sworn upon oath says that information
provided'in this application is true and correct. I understand it is a violation of the Texas
;,~i ropractic Act to~submita
f~ls~ s~nt to the b.oard. Sworn and subscri~ed to before
sigr.iat~re.appears
the-said (Owner)
~/ d.--1
this the
Signature
~ Ff f1'
day
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State of
~f,(Q. S
Te...K CLe-
Should you have any questions regarding this application; contact TBCE at
(612) 306-6700.or email. to tbce@tbce.state.tx.us
Form 101p3
Ver ..0:412012
All q~estions must be answered. A fac;:lllty owner must be 21 years or older. Gl.ve the name of the ~aclllty that you
own 1Oo/o or greater in. Sign the certification and attach to the Faclilty Application or Renewal Form
City
Address
feR-
I0.5
ZIP
-r.
:Su~
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VI 'f1C.
Additional Owner/Partner
Name (First)
Suffix
Last
131!-a. m
Gender
F-Female
~Male
Eth.,lty
i;;;:tW-White
D B-Black
H-Hispanic
D P-AsianlPacifrc Islander 0
D OOt~er
Homecen No.
City
ZIP Code
County
7/1T/".ft7\J T
An OWNER/PARTNER WITH A10o/o OR GREATER INTEREST IN THE FACILITY MUST ANSWER ALL QUESTIONS.
FAILURE TO ANSWER 'ALL QUESTIONS WILL DISQUALIFY YOUR FACILITY APPLICATION OR RENEWAL.
FACILITY QUESTIONNAIRE
8Do you own chiropracti.c facilities in other state{s)? 0 Yes g-No
If ves list the state(s) of licensure and your facility reoistration number in the other states(s)
State(sl Licensed
Facilltv Number
F: acilitv Number
Statelsl Lieensed
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&Have you ever been the subject of a disciplinary action by the Texas Board of Chiropractic Examiners or any
other chiropractic licensing agency and/or disciplinary.authority of ~nother stat~ (5xamples: Revocation,
suspension of license, administrative penalty, or letter of reprimand.) D Yes Ei}-1Q'o
If you answered Yes, include the name of the Board, licensing or disciplinary authority, the date of the order,
date.at termination
ot the con d'1t1on
andror oro blem.
and ifaoolicable
the
Name of Board
Ucel!SinQ/Disciolinarv Authoritv
Date of Order
Fonn 101A
Ver. 04/2012
.Facility Questionnaire
~er/Pt;; Name
62
. -()
c.
eHave you ever been convicted.~~ felony or misdemeanor other than a traffic offense, bt,1t. including a drug or
alcohol-related offense?
Yes LMNo
OH~ve y~u been.subject of~ deferred a~judicaUon for a~~Y or misdemeanor other than a traffic offense,
but:mctud1ng a drug or alcohol-related offense?
Yes' VNo
If you answered Yes to Question(s) 3 or 4, provide details on.each conviction including offense, punishment,
date of conviction, whefheryou were incarcerated, and if you are currently on prol)ation or comml;!_nity
supervision. To expedite.your application, you should notify the Board immediately of any convicti9n so that
they may send you additional. materials required for processing your application
Type of. Offense
Punishment
Conviction
Date
Incarcerated
Yes/No
Probation
Yes/No
Commuryity
Suoervlslon
..
St_;ate law prohibits renewing a license more than on~e after a licensee has defaulted on any student or
TGSLC loan. You should contact your student loan institution or TGSLC before . completing this.form. Texas
Administrative Code 73.2, 80.2
Your license will not, be renewed Bf'!d s~spend~d if inforniation is received from the Attorney G~nerat's Office,
State.of Texas that the applicant is in:default of their Child S1,1pport Agreement per Family Code, Chapter22
Suspension of'Ucerise, 232.003
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.-
_Fonn 101Ap2
Ver. 04/2012
Facility Notarization
Texas Board af Ghirapractic Examiners
State law prohibits renewing a license more than ()nee after a licensee has defaulted on any
student or TGSLC loan. You should contact your student loan institution or TGSLC before
completing this form. Texas Administrative Code 73.2, 80.2
Your licensewi'll riot be renewed and suspended if information ,is received from the Attorney
General's Office, State of Texas that the applicant is in default of their Child Support Agreement per
Family Code, Chapter 22-Suspension of License, 232.003
Before me, theundersigned authority, on this day personally appeared the applicant whose
signature appears below, and who being by me.sworn upon oath says that information
provided. in this application is true and c9rrect. I understand it is a violation of the Texas
Chiropractic Actto submit a false statement to the board. Sworn and subscribed to before
me,
the said (Owner)
I
of
//
_ /
(/
{j&0--L
.J---Signature
this the
:z~r-day
,20..J_j_,
County of
~~;;,.,.
.. );_.~l~!
Mv Commission Expires
State of
JJtt llM
--
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(seal)
Should you have any questions regarding this application, contact TBCE at
(51-2).305.,.6700 oreniall to tbce@tbce.state.tx.us
Form 101Ap3
Ver. 04/2012
,., s.: ..
TexasJ.B~rd ofChiropra~c.~~ii:iers
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F~C:IC.IT;Y: 'Ql!JES1Ti10NNAIRE;
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'State(s)1:icensea
FacmtV~Number.
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i~~~~~~Q~fj~~~~~:~~a~\i?~-~9~~;n;~~~f~:~rr~~~~j~i:~~~~%~~i~!}~p~-~!~~~;~~x~rnP1~s: . ~ev.q9atiQ:n-.
. ,_ .
If.you answered Yes;,:mclude;themameof-the Board, 'lrcensmg ord1sciphnary.:autlionty, the date oftheorder;
~.~ij Jr"""-,.~
~.nti'a.coil
d't'
11on,an-d,or.oroblem._
aoo11ca. -bre.rl1r~dT
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Name
of.eoattH
.1Jcerisli1&al&cli:illnimi'AtithorttV
I
Date of Older
Tennination Date of.Condition.
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TBCE ACiditionali=acllity OWnerJPartner wilh 10%
t ,."
Interest:
..
Contmueon;to.next.pc:ige
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'Fonn.io1A
Ver. 04i2012
.<:
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All questions must be answered . A facility owner must be 21 years or older. Give the name of the facility that you
own '10% or greater In. Sign the certification and attach to the Facility Application or Renewal Fonn
f'clllty Name
t.. 7
..
H~Hispanic
l-;J(Ji7h L~
L_M(;z.
D 8-Black"
City
Address
/t
lo Deckt-r (ovr{
Tr-v.Yi
State
T.x
P-Asian/Pacific Islander
0.0-0ther
ZIP Code
c~
J._
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An OWNER/PARTNER WITH A 10% OR GREATER INTEREST IN THE FACILITY MUST ANSWER ALL QUESTIONS
.FAILURE TO ANSW.ER.ALL QUESTIO.NS WILL DISQUALIFY' YOUR FACILITY APPLICATION OR RENEWAL.
FACILITY QUESTIONNAIRE
~o
FacilltV Number
State(sl Licensed
Facility Number
8Have you ever been the subject of a disciplinary action by the Texas Board of Chiropractic Examiners or any
other chiropractic licensing agency andior disciplinary autho.rity of another sta~?.{Examples: Revocation,
o
suspension of license, administrative penalty, or letter of reprimand.) 0 Yes
lf:you answered Yes, include.the name ofthe Board, licensing or disciplinary t ority, the date of the order,
t f termma
. f1onof th econ dT
11on an diororo bl em.
an d I'f aao11ca bl e; th e d aeo
Name of Board
Ucensinnrnlsclallnarv Authoritv
Date of Order
Fonn 101A
Ver. 6412612
Facility Questionnaire
H.. ave you e.ver been convicted:!elony.or misdemeanor other than a traffic offense, but including a drug or
alcohol-related offense? D Yes
o
8Have youbeen subject of a def rred adjudication for ~ony or misdemeanor other than a traffic offense,
but including a drug or alcohol-relat~d :offense? D Yes o
If you answered Yes to Question(s) 3 .or 4, provide details n each conviction including offense, punishment,
date of conviction, whether you were incarcerated, and if you are currently on probation or community
supervision. To expedit your applica.tion, you sho1,lldnotifythe Boardjmmediately of any conviction.so.that
they may send you additional materials required for processing your application
Type of Offense
Punishment.
Conviction
Incarcerated
Probatl6n
Date
YestNo
Yes/No
Community
SuceNislon
Stat~law prohibits renewing a licensernore'than once after a licensee has defaulted on any student or
TGSLC loa!l. You.should con~act your stuqef'.)t loan institution or TGSLC before completing this form. Texas
Administrative Code 73.2, 80:2
Your license will hot be renewed and suspended if information is received from the Attorney General's Office,
State.of Texa.s ttJat the a,pplica~t is in default"of their Child Support Agreement per Family Code, Chapter 22Suspension of Liqense, 232.003
jt
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Fonn 101_Ap2
Ver. 0'.412012
Facility Notarization
'
State law prohibits renewing a license:more th.an once after a licen$ee has defaulted on any
student or TGSLC loan. You should contact your student loan institution or TGSLC before
completing this form. Texas Administrative Code 73.2, 80.2
Your license will not be renewed and suspended .if information is received from the Attorney
General's Office, State of Texas that the applicant is in default of their Child Support Agreementper
N~ 11/rth(hl(h_
County of
,,&m~
f~~~ ~
State of
Ll.J..-:'
~~
(seal)
Fonn 101A.P3
Ver. 04/2012
.1~~JI'
CARRfCK
~~ r-1 BRAIN CENTERS
T5J 1!EIEO~IE~
I~
04/24/2014
Carrick Brain Centers
I 05 Decker Ct. Suite 120
Irving, Tx 75062
APR 1 ~
201~ 1M
TfAAS BO~RO Of
CtllROPAACTIC o.AMINERS
Dear Jennifer,
Please add the following license numbers & update
the
855444,2724. www.carrickbrajnq:nters.com
__-_ -_ - ________
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NAME
! Gary
~H
License Number
Records
10447
Found
10540
-~
CP
lcaganI
Randall
ACTIVE
Date Expir es
Osle Received
Date Pr~
2/112014
21112015
2/1/2016
7/1912013
1116/2014
1212112014
7/2312013
112112014
1212212014
2013-2014
2014-2015
2015-2016
7/23/2013
Unsorted
Accounti .......,
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7119f2013
7119f2013
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