TBCE Date Stamp FOR OFFICIAL USE ONLY

BC $75 MO PC Application Fee Tracking Number

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

A facility' 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) Legal. Facility lnfonnatlon

l;aclllty Name C...d..rr/L.K.. i3rfl,,t1 C-e11fFacility d/b/a Name, if applicable

Street lo~ City - ./-fl/IJ1 f)p c ke IL. ( o t.trT, .rrG County TelephoneNo. Fax No.

()lq 1- rlK8 5 7 2 5'"1 Z - 3 0?. 0 Facility Mailing Address (If different) Street City

County I Telephone No. Fax No. Stale

E-mail Address

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

I ZIP Code

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

I._ H.g~-w ..... rna-ny-l!l-d"""'~=~-ID-='a""-c- _1 __ ___.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 ii~1:'i~rate business identities, including l:iilling, accounting,andother functions; D Yes [if'No If yes. since what date? 1 .

(mm~/ym) --- I z ~ Has this facilitycommenced providing chiropractic services? !2rfes 0 No If yes, since what date? J '""1"1 ~ "2- 1 I)

; ~/. \ i - :, .:_ I (inm/~~/yyyy) Is this facility the primary office? ~Yes D No If no, whatis the fucility numberofthe primary office? '"'

.. . ~ .... , ;. Have you ever owned a chiropraotfuftaciutYfin Texas? D Yes CiJ'No If yes. give facility lic~nse number: {mm/ dd/yyyy)

(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..,

Hours.worlled.at this lcicallon bY day M ..---r- ,.,-W_ --TH

Days work@d at this.location .. M. 0-J[JW~A-~0 License No. Name (first) LasfName

Days worked atthls location M DTDWOTH D FD so

Hours woi'ked al this location by day M T W TH F s

License No. Name (first) Last Name

Days worke'd,at this'locatio~ M0T0W0TH0F0S0.

Hours worked at this location by day M T W TH F s

er SUBMIT A ffiRM IDIA FDR EACH OWNER/PARTNER WITH A ID% 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)? 0 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

bl the condition and/or.ore em. Name of Board Llcenslng/Dlsclpllnaiv Authorltv Date of Order Termination Date of Condition

.

eHave you ever been convicted of.' a felony or misdemeanor olherthan a traffic offense; but Including a drug or alcohol"relaled offense? 0 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

~ r r anv.conviciion so lhal thev mav send.vouaddilional materials reaulred or orocessrm vour aoo11ca ion Type of Offense PunishrtJent Conviction

Date'

TBCE Facllity Application

Incarcerated Probation YestNo YesJNo

Community Suoervislon

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 sigr.iat~re.appears 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 ;,~i1ropractic Act to~submita f~ls~ s~nt to the b.oard. Sworn and subscri~ed to before the-said (Owner) ~ / d.--- this the ~ Ff f1' day

1 Signature

ot. __ Cfjt-rr ...... J..._

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 1 Oo/o or greater in. Sign the certification and attach to the Faclilty Application or Renewal Form

Address City ZIP

feR- I0.5 :Su~ -r. VI 'f1C. 7-S-() b 2... Additional Owner/Partner Name (First) Last

131!-a. m Suffix

Gender 0 F-Female ~Male

Eth.,lty i;;;:tW-White D B-Black D 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

7/1 T/" .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 Statelsl Lieensed F: acilitv Number

- -' ...... ., ... --. . f"~ ...... -.-":""'!-'!"'. k . -

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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,

t t d' dr bl and ifaoolicable the date.a termination o the con 1t1on an Name of Board Ucel!SinQ/Disciolinarv Authoritv

TBCE Additional Faclllty'Owner/PartnerWlth 10% Interest

or oro em. Date of Order Termination Date of Condition

Continue on to next page

Fonn 101A Ver. 04/2012

.Facility Questionnaire

l ~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? D 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? D 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 Incarcerated Probation Commuryity Date Yes/No Yes/No 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

:-... .. ,_ ... -~ ... >_.,.~~~ ~ -- ..... ~- ._. ... ,.~. u.

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' -. ,.., ,. \( I .- ~ statement to the board. t -- - . _ ~ .:. . - ::- . 1~ "'c.4'""""'~1n,.,, .... , .. ,...,.\_t.-.,_.,. ..... ~ .. ..:.. ..... ~ .. "" -;;,.._...r-;;.M""..

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) ~ (/ .J--- this the :z~r-day

I Signature

of {j&0--L ,20..J_j_, to certifywitness to my hand and seal of office ..

~~;;,.,. KELLIE KAY BECKER ft:K:J.'f'\ Notary Public, Staie of Texas-.. );_.~l~! Mv Commission Expires ~ .. ~~!!!.~~,..- September 09, 2014

(seal)

County of JJtt llM --State of I ~)

. I ; . I

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tEXAS' aoAR~l;OfiCHIROPRACT:IC !EXAMINERS _., ~~}i~~i9~~~~!ff~~iMW~Q~~!!J~!-r!ri~{wift1>109X i't1t~t~si ..

TexasJ.B~rd ofChiropra~c.~~ii:iers rt ..... ~~~~~~6W~~:{jfo~~3~?.., 1 '

':- (51~po~ioo. . F~ {512) ~5:.6705' 'I

',.' 1.--: .I ~ .J ~ .. ; .. ~ .. , !~ ... J .:.: f ;; .. A.ii .~"~f,P.l[9.P.~~J;;,.{~9i!m~ W.r9!b,~! ~~(~)J. }i;t..~~ ~f;_~~ .. .~~~-'~ \~ .. ,rf" . ~\ ~r,-~~~~-. ~""' '?.Y(l.~ _lhes,IJsMneistate(s)of l1censure and .vour:Aac1litV~rea1strat1onJ.number 1n the.otherstates(s) .. A~ .~~t-1\..~...,. ~"'\cc

CStatets~fUcensedi. : . ~~cil~~iNumbef 'State(s)1:icensea - FacmtV~Number. ! ! .. _ __ .'.' - .. ~. _. --~ ~ ~ ---~xr=._ - _.,.,..':-./-- ,-....::. -. - . _..... - - ... .:._.

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+

. "'"" tlf 1" -. ' 11".- .. -,, .._ ' l".--- '. - - - ) .: - 4 I.,.,,' -.o ,. ' . ,.._~_..-. 1-' C !.H!!..V:~,Y~~-'~"'.~.~.b,~~Qrtrye:~_tjj~ct:\Qfi~1~ls.~,!Plin_~iy:.~ctiol) __ l)y_mer.e_xa~J3o~r~~of:~.~irqpr~c~ic;::~~a_rnin~.~:or~ny 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 r"""-,.~ .. -br l1r~dT -tr- .. ~.- -c .. .. nti' d't' -d, bl an J aoo11ca e.r 0 aeo enmna 1omo a.coil 11on,an or.oro em._ - -

I -

Name of.eoattH .1Jcerisli1&al&cli:illnimi'AtithorttV -

Date of Older Tennination Date of.Condition. - ---- - - -

-

I

I -

- -

'.

..

-

'

# t ,." Contmueon;to.next.pc:ige

. '-. \;.

TBCE ACiditionali=acllity OWnerJPartner wilh 10% Interest: 'Fonn.io1A Ver. 04i2012

-

I

i

.plic~tlon~ c()ritact :'tBCE~at (512) 305-67()0

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 _ /t .. L_M(;z. l-;J(Ji7h L~

Address

lo Deckt-r (ovr{ City

Tr-v.Yi State T.x

D 8-Black" D H~Hispanic 0 P-Asian/Pacific Islander O I-American Indian Alaskan Native 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 ODo you.own chiropractic.facilities in otherstate(s)? D Yes ~o 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, suspension of license, administrative penalty, or letter of reprimand.) 0 Yes o lf:you answered Yes, include.the name ofthe Board, licensing or disciplinary t ority, the date of the order,

d 'f r bl th d t f t . f f th dT di bl an I aao11ca e; e aeo ermma 1ono econ 11on an ororo em. Name of Board Ucensinnrnlsclallnarv Authoritv

TBCE Addltlonal Facility Owner/Partner Wilh 10% lnleresl

Date of Order Termination Date of Condition

Continue.on to next page

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 Community Date YestNo Yes/No 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 22-Suspension 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.

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_ ,,&m~ KELLIE KAY BECKER f~~~ ~ Not.11rv Pu bile, State of Texas \j-.R~~i My Commissi~n ~xpires

~i!.~~.ll' September 09, 2014 (seal)

County of Ll.J..-:' State of ~~

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 04/24/2014

Carrick Brain Centers I 05 Decker Ct. Suite 120 Irving, Tx 75062

Dear Jennifer,

T5J 1!EIEO~IE~ I~ APR 1 ~ 201~ 1M TfAAS BO~RO Of

I CtllROPAACTIC o.AMINERS

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

FileMalcer Pro - [Fact __ -_ -_-________ ~ _ _ Cl 1- x- [iii File Edit View Insert Format Records Scripts Window Help x J D ~ l ~ ~ I lb ~ el.,,l '@J~~ l fll: l ~ ~11$ 14' l rz! I Accounti ....... , Facility Accounting Information ~ ~ NAME ! Gary lcagan I Randall I ACTIVE I I ~ Date Expires Osle Received Date Pr~ Ye&1 Pay ing License Number H 2/112014 7/1912013 7/2312013 2013-2014

-Records 10540 H 21112015 1116/2014 112112014 2014-2015 10447 CP 2/1/2016 1212112014 1212212014 2015-2016 -~ J Found 1 7/23/2013

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Date Received Date Prooess.ed

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02/:~~~1:- ] Y 7119f2013 7119f2013 $75.80 . """""""'

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