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TBCE Date Stamp

FOR OFFICIAL USE ONLY

$75

BC
PC

MO

Tracking Number

Application Fee

l/fllt~~ ~-=-:~::;-;:;n"".;:;r.=ti?(1CILITY APPLICATION '0:95~.4 f):


!~~~~~~rr~ of Chiropractic f;xaminers

.r..

333 Guadalupe St.. Suite 3-825


Austin, TX 78701
12) 305-6700
FAX (S12) 305-6705

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

Legal. Facility lnfonnatlon


Street

lo~

C...d..rr/L.K.. i3rfl,,t1 C-e11f<!f

Facility d/b/a Name, if applicable

f)p c ke IL. ( o t.trT, .rrG


()lq

./-fl/IJ1

Fax No.

TelephoneNo.

County

City

1-

rlK8 5

72

5'"1 Z -

3 0?. 0

Facility Mailing Address (If different)


Street
County

I Telephone No.

City

Stale

Fax No.

E-mail Address

ZIP Code

Primary or Managing Partner Check if facility is O Sola Proprietorship Gtflartnershlp O Corpnration.


AU additinnel facility owners/partners with etleest a ID% or greater ownership interest must be provided. list all additionel owners/partners on separate Form IDIA.
Rule 174~2(b) The a licetion must be si ned b the.owner.. if.a sale ra rietorshi , orb sn authorized rs resentative, ii a artnerslii or car oration.

0'1-American Indian/Alaskan Native

0 0-0ther

Home Telephone No.


ZIP Code

H.g~-w
.....
rna-ny-l!l-d"""'~=~-ID-='a""-c-_

I._

_ ____.I

SIGNATURE REOUIREO.

TEiCE Facility Application


.Fonns available al www.tbce.sta!e.l/!.us

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?

ii~1:'i~rate business identities, including l:iilling, accounting,andother


1.

(mm~/ym)

Has this facilitycommenced providing chiropractic services? !2rfes

~/.

\i

Is this facility the primary office? ~Yes

. .

.... ,

- :, .:_

---

J '""1"1 ~

No If yes, since what date?

No If no, whatis the fucility numberofthe primary office?

;.

Have you ever owned a chiropraotfuftaciutYfin Texas?

D Yes

CiJ'No If yes. give facility

"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

Hours.worlled.at this lcicallon bY day

..

M. 0-J[JW~A-~0
License No.

Days worked atthls location

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

Days worke'd,at this'locatio~

Hours worked at this location by day

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

TBCE Facllity Application

Fonn 19.~p2
Ver. 04/2012

Facility Notarization

Texas Board af Chiropractic.Examiners

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

ot. __Cfjt-rr. .J..._<f\..R


. ......_ _ _ _ _ _ _,20

~ Ff f1'

day

I~ ,

to certify witness to my hand and seal of office.

K~w I{.

3leJJft-

Notary Publ!c in an:tdr the


County of
~m1~

/.~~~!\'~';11.\

!~
.i.,I
~t:.rm~i'

'h"""

KElllE KAY BECKER

Ncnary P~bllc, Stete of TeJCes~


Msv Commission E>1pires

State of

~f,(Q. S

Te...K CLe-

eptembet, 09, 20hl

Should you have any questions regarding this application; contact TBCE at
(612) 306-6700.or email. to tbce@tbce.state.tx.us

TBCE Facility AppllcaliOll

Form 101p3

Ver ..0:412012

TEXAS BOARD OF CHIROPRACTIC EXAMINERS


Additional Facility owner/Partner :With 10% Interest
Texas Board of Chiropracdc Examiners
333 Guadalupe St.. Suite 3-825
Ausiin, TX 78701
(512) 305-6700
FAX (512) 305-6705

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~

7-S-() b 2...

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

I-American lndianlAlaskan Native

D OOt~er

Home Address - Street.

Home Telephone No.

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

. -. . . ' :i/

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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

Termination Date of Condition

Continue on to next page


TBCE Additional Faclllty'Owner/PartnerWlth 10% Interest

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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I certify thattheinformation I have provided tothe abovea~pl.i~~iionah7ci'~~e.s.tion~:a~e:true


and correct. I understand that it Is a violation of ttle Texas ;hiropractic Act to' subin'ff.aifalse
'
\
' "J'
-. ,.., ,. \(

statement to the board.


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TBCE;facllity Application -AddiUonal ~er/Partner Wiih 10% Interest

.-

_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_,

to certifywitness to my hand and seal of office ..

County of
~~;;,.,.

KELLIE KAY BECKER

.. );_.~l~!

Mv Commission Expires

ft:K:J.'f'\ Notary Public, Staie of Texas~..~~!!!.~~,..-

State of

JJtt llM

--

I ~)<.

Ci..

September 09, 2014

(seal)

Should you have any questions regarding this application, contact TBCE at
(51-2).305.,.6700 oreniall to tbce@tbce.state.tx.us

TBCE Facility Application - Addillonal OWl'ters with 10% interest

Form 101Ap3

Ver. 04/2012

,., s.: ..

TexasJ.B~rd ofChiropra~c.~~ii:iers

,t::- ..

',.'

rt.....

"'

tEXAS' aoAR~l;OfiCHIROPRACT:IC !EXAMINERS


_., ~~}i~~i9~~~~!ff~~iMW~Q~~!!J~!-r!ri~{wift1>109X i't1t~t~si ..

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. F~ {512) ~5:.6705'

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. A.ii <iH~Jipn~;;ri~~*1~-'l~.'-1~W::~re~_. ~\f!~IJlfy o~"~~r1m!i:S~~-~~2i Y.t!.~~~rcil~er,: ~ive:~lle:na.inf)~f''1e fac(i1ty;tha~;y~u.


''Cl~n'1.Q/.o ~r~~~~er.:ln;,iSlgrrthe (!~rjln~a~l.9-.!l:~n~ a~cM~ .t,he.Fac,ll_lty,:APPJ!~l!q~fl or~~~~' FO_"'!
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if

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:Home TelejihoneNo.- ,

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' ~.~;9,~N.~J~l~~~!Nr;i3\Y!lt!i~.:~91'~'QB'GR~A!i~'!il~t~~E~F!~.''.t.t1~:J=J1'9.'.!i!rtt~!'Ot~N~W,i;~-~-L!;,'gyerto~s~

" FAll.::tJRElTO ANSWER.ALJtQUES:rroNS .WILL,OISQUALIF~WVOUR FAClltlr.l, ARP.L'..ICATION.'.ORiRENEWAL..


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A~ .~~t-1\..~...,. ~"'\cc
CStatets~fUcensedi.
: . ~~cil~~iNumbef
'State(s)1:icensea
FacmtV~Number.
! ! .

_lhes,IJsMneistate(s)of l1censure and .vour:Aac1litV~rea1strat1onJ.number 1n the.otherstates(s)

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i~~~~~~Q~fj~~~~~:~~a~\i?~-~9~~;n;~~~f~:~rr~~~~j~i:~~~~%~~i~!}~p~-~!~~~;~~x~rnP1~s: . ~ev.q9atiQ:n-.

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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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1omo
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:

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Ver. 04i2012

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ShQuld,:yq,u hay:!{!!,~Y/q l!es!t~n!'-~~9!~9!~01:t~.i~:~i>plic~tlon~ c()ritact :'tBCE~at


(512) 305-67()0<or em.all[totbce@tbce;s~te.tX;us

:r&cei-F.acilltY,Application __ Additlona1 ciWner5-wtth 10_"ib_lnter:es1

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TEXAS BOARD OF CHIROPRACTIC .EXAMINERS


Additional Facility Owner/Partner With 10% Interest
Texas .Board of Chiropractic Examiners
333 Guadalupe SL, Suite 3-825 .
Austin, TX 78701
(512) 305-5760
FAX (512) 305;.{)705'

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

O I-American Indian Alaskan Native

P-Asian/Pacific Islander

0.0-0ther

Home Tel~~ne No.

H'f'.e Cell No.

ZIP Code

c~

J._

I t.L-vr~

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

ODo you.own chiropractic.facilities in otherstate(s)? D Yes


If. yes list the state(s) of licensure and your facility registration u ber in the other states(sl
State(s) Licensed

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

Termination Date of Condition

Continue.on to next page


TBCE Addltlonal Facility Owner/Partner Wilh 10% lnleresl

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

I certify that.the information I have provided


and corr t. I understand at it is

stateme t to the board.

TBCE Facility Application -Additional ONner/Partner With 10% Interest

the above app,lication: ancf~qU.ii'stionS.<ariftfe


f the Texas Chiropractic Act' tO sublriit~ :false

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Fonn 101_Ap2
Ver. 0'.412012

Facility Notarization

Texas Board .of Chiropractic Examiners

'

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

Family Code, Chapter 22~Suspension of License, 232.003

to certify witness to my hand and seal of office.

N~ 11/rth(hl(h_
County of

,,&m~

f~~~ ~

KELLIE KAY BECKER

Not.11rv Pu bile, State of Texas


\j-.R~~i My Commissi~n ~xpires
~i!.~~.ll'
September 09, 2014

State of

Ll.J..-:'
~~

(seal)

Should you have any questions regardlngthis application, contact TBCE at


(512) 3056700 or email to tbce@tbce.state.tx.us

TBCE Facility.Application -Addllional O'Mlers with 10% Interest

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

facility certificate for Carrick Brain Centers:

Dr. Jake Shore.s: 12428


Dr. Randall: 12225
Dr. Brock: 8026
Also, please send the "Complaints" plaque so we can include this at our facility.
Thanks,
Jenni for

Carrick Brain Centers

855444,2724. www.carrickbrajnq:nters.com

105 Decker Court, Suite 120 Irving, TX 75062

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NAME

! Gary

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License Number

Records
10447
Found

10540

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CP

lcaganI

Randall

ACTIVE

Date Expir es

Osle Received

Date Pr~

Ye&1 Pay ing

2/112014
21112015
2/1/2016

7/1912013
1116/2014
1212112014

7/2312013
112112014
1212212014

2013-2014
2014-2015
2015-2016

7/23/2013

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Facility Accounting Information

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Date Receiv ed Date Prooess.ed

7119f2013

7119f2013

$75.80

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