OF PAARP 10 LICENSE NUMBER NAME OF APPLICANT BUILDING BRIDGES, INC. REGISTERED WITH. MT SEC OF STATE DATE. RECEIVED Other Names Known AS Or DBA: DATE APPLICATION EXPIRES Aw COMPLETED APPLICATION REGISTRATION FEE - 0-10 $500.00 REGISTRATION FEE - 11-50 $3,000.00 REGISTRATION FEE - 51?100 $6,000.00 REGISTRATION FEE 101 $9,000.00 OWNERS LISTED EMPLOYEES LISTED ACCREDITING ENTITY NATSAP FEES RECEIVED. LICENSE FEE 0?10 $260.00 LICENSE FEE - 11-50 $300.00 LICENSE FEE 51-100 $1,600.00 LICENSE FEE - 101 $2,400.00 PLAN OF OPERATION INCLUDED OTHER REQUIREMENTS PERSON IN CHARGE KURTIS FAIRBANK 6/30/09 Background Check LICENSE HISTORY LICENSE VERIFICATION RECEIVED LIST STATE OR STATES LICENSED ACTION STATE DISCIPLINARY MISCELLANEOUS COURT OTHER #13 "yes" Steve Fairbank ACTION DOCUMENTS PERSONNEL INFORMATION 5 PERSONAL HEALTH IMPAIRMENT ISSUES OTHER ISSUES Steve Fairbank 407-LAC BOARD LETTERS TO MEDNDENCE APPLICANT DATE DATE GIVEN APPLICATION COMPLETE TO PM APPLICATION REVIEWED BY REVIEWED BY INITIALS AND DATE BOARD APPROVAL AND DATE APPROVED INITIALS AND DATE DATA COMPLETED IN WALL CERTIFICATE AND: COMPUTER LICENSE SENT . - PAP Req App . REVISED 05/08 MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL DR Page 3 of 7 OUTDOOR PROGRAMS . (301 PARK, 4TH FLOOR - Delivery) WT . PO Box 200513 Helena, Montana 59620-0513 ?id-"m mug-IBM PHONE (406) 841-2392 or (406) 841-2369 FAX (406) 8414305 I, ,3 '3 ILL EMAIL: WEBSITE: 52 PROVISIONAL LICENSING REGISTRATION (Includecopies of all requested documentation) AVERAGE DAILY CENSUS: . I I 0-10 Participants 11-50 Participants 51-100 Participants 101+ Participants 1. BUSINESS Sole Proprietorship if: Partnership I: Other I Limited Liability Professional CorpOration Non-Professional Corporation 2. BUSINESS Non-Pro?t Pro?t Ff Out-of-State If the Business is incorporated out-of~state, list the state of Incorporation Mo 1: fandL Please provide the address of your Corporate Headquarters P0 Ba): 0 7, I Graces Cree?K 2d,. MT 59?5?73 Registered in Montana with the Secretary 3. DATE BUSINESS ESTABLISHED of State? ?nes r: No 4. BUSINESS ENTITY NAME Ida/1g Brag; Inc 5. FEDERAL TAX ID OR SOCIAI SECURITY 6. BUSINESS PHYSICAL ADDRESS /00 Graves Crux Pd 7. MAILING ADDRESS PO Box [310' 8. BUSINESS TELEPHONE NUMBER (906)897 ~9?53 FAX (404.) - 9255/ 9. BUSINESS EMAIL ADDRESS 51; 10. BUSINESS WEB SITE: Boilqubnq?esrne. ner I Would you like your website address listed on the Montana Board of Private Adolescent Residential or Outdoor Programs Website? Yes No pAp Reg App Page 4 of 7 REVISED 06108 . 11. LIST ALL NAMES OR IF YOUR BUSINESS IS A CORPORATION, LIST ALL . NAMES: (Please provide other ?ames on a separate sheet of paper and attach to the registration application.) LAST NAME FIRST NAME MI PHONE NUMBER 1 I ?5wa #06532795963 $3913sz I . ?t?mt 10m" . am- M97305 12. PLEASE NAME THE INDIVIDUAL WHO IS RESPONSIBLE FOR THE CONDUCT OF THE PROGRAM 3 (please complete the "Individual Employee Report Farm" on Page - I) ?093239553 Name I Position Contact Phone Number 13. PLEASE LIST ALL CURRENT PROFESSIONAL AND SUPERVISORY EMPLOYEES AND RELEVANT CREDENTIALS AND OTHER QUALIFICATIONS: Please provide other quali?cations on a separate sheet of paper and attach to registration application. (Pfease have each listed employee complete the "Individual Employee Report Farm" on Page 7). - LICENSE NUMBER, map LAST NAME FIRST NAME MI STATE WHERE LICENSED POSITION . A I I: I: . - 40?7- 55019.0? on . 57302, -- ?aw] Fatwa 14m 1 comm 1% - I Aha/95127: Vivian) Lagging!ng I I Please make copies of this page as needed.- PAP Reg App REVISED 06/08 Page 5 of 7 For the individual named in Question number 12. (person responsible for the conduct of the program), and each current professional and supervisory employee listed in your answer to Question number 13, please list the following: (Please use the "Individual Employee Report Form" (Page 7) for each person named in question #12 and 13). al C. 14. List all other professional licenses (other than your original state of licensure) that the listed individuals have held and that have been current (whether active or inactive) at any time during the past five (5) years. If you need additional space, you may attach a separate sheet of paper. Failure to list all licenses active or inactive during the previous five years constitutes a falsi?cation of your application and will result in a denial of your application and or disciplinary action. For each individual, professional or supervisory personnel referenced in your answers, indicate whether a licensing agency has ever taken adverse or disciplinary action against the listed person?s license. (For each person listed above and where the answer is "yes" attach agency documents ?led in the action including all complaints, initiating documents, orders, ?nal orders, stipulations and consent andfor settlement agreements.) Yes No For each individual, professional or supervisory personnel referenced above, indicate whether heishe has ever voluntarily surrendered, cancelled forfeited or failed to renew a license as a result of any of the following: having a complaint ?led against you; entering into a consent agreement with respect to your license as a result of a complaint, during an investigation or during disciplinary proceedings. (If yes, attach a- detailed explanation identifying each occasion, the date and the substance - of the allegations, along with agency documents ?led in the action including all complaints, initiating documents, orders, ?nal orders, stipulations and consent and/?or settlement agreements.) yes Has any legal or disciplinary action been filed against a person/individual referenced above, (including malpractice, etc)? If yes attach a detailed explanation of each instance including the date of the claim, name and address of party complaining, name and address of forum or court where claim was filed, docket or claim number and the substance of the allegations. Yes - No Please list "your p'rograrnffacility is including registration or licensing through another state agency in Montana. Pe?rs?ret. g; 0 Bo. RA. ABOAP PAP Reg App REVISED 06/08 Page 6 of 7 15. Please list whether your business entity/program is or has been licensed in another state. List all-other professional licenses (other than your original state of licensure) that the listed business has held and that has been current (whether active or inactive) at any time during the past five (5) years. State in Business Name of Program which licensed License num bar Date of . Li ?censure Type of cense ?vi/A oxidise? can: 22/; - gun/aha F?cutMmleR. 16. Has a licensing agency ever taken adverse or disciplinary action against your business entity license? (For each person listed in 12. or 13., and where the answer is "yes" attach agency documents ?led in the action including all complaints, initiating documents, orders, ?nal orders, stipulations and consent and/or settlement agreements.) Yes ENG DECLARATION As the Person-in?Charge, I authorize the release of information concerning the record, character, license/registration history and competence of this facility, by anyone who might possess such information, to the Montana Board of Private Alternative Adolescent Residential or Outdoor Programs. 1. hereby-declare under penalty of perjury the information included in this application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or incomplete answer to any question may lead to denial of this application or subsequent revocation of licensure on ethical grounds. I have read and am familiar with the licensing laws of the State of Montana and instructions to applicants for registration. I accept the rules and procedures outlined in these documents as the basis for this application. - aw age/as Signature of Person-in-Charge Date PAP Reg App REVISED 06mg Page 7 Of 3" MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL OR OUTDOOR PROGRAMS (301 PARK, 4TH FLOOR - Delivery) - PO Box 20051-3 Helena, Montana 59629-0513 PHONE (406) 841-2392 OR (406) 841-2369 FAX (406) 841?2305 EMAIL: 91mm INDIVIDUAL EMPLOYEE REPORT FORM Please use this form in answering #12 and #13, and on page 5 of the application for each employee and the person-in-charge of the program. Please make copies as needed and attach to application Employee Name' ?Fai?d?ya/yxfo saga POSition DWTO l? . a. Professional licenses held (active or inactive) at any time-during the past ?ve years. DATE OF LICENSE AND TYPE OF LICENSE STATE OF LICENSE ACHVEIINACTIVEIEXPIRED 407?! Me. 407 glam (q/i?q/OB - a: 3/ 31/ 96a. A577 ye. b. Has a licensing agency ever taken adverse or disciplinary action against your Iicense(s)? If "yes" please attach agency documents filed in the action including all complaints, initiating Yes ND ts,dfild,lii 1:5. 5 acumen or ers, no or are stpuatons an consent an lors eme agreemen c. --Have you ever imluiitarilyr surrendered, cancelled, forfeited or failed to renew a license as a result of any of the following: having a complaint ?led against yeti; entering into a consent agreement with respect to your license as a result of a complaint during an investigation or during disciplinary proceedings, g?res No If "yes", attath a detailed explanation identifying each maslon, the date and the substance of the allegations, along with agency documents ?ied in the action including all complaints, initiating documents, orders, final orders, stipulations and consent and/or settlement agreements. d. Has any legal or disciplinary action been filed against you, (including malpractice, etc)? If f'ves", attach a detailed eacplanation of each instance including the date ofthe claim, name and Yes No address of party complaining, name and address of forum or court where claim was filed,? docket or claim number and the substance of the allegations. I I Signature Date E. State of Montana is holding all documentatien from that ?me peried. See Breeneif any questions. C. Result was stipulated on my license that I will not counsel females. Documents same as above. MONTANA BOARD OF pawns ALTERNATIVE ADOLESCENT RESIDENTIAL OR OUTDOOR PROGRAMS Page 7 ?f 7 (301 PARK, 4TH FLOOR - Delivery) . Po Box 200513 Helena, Montana 59629-6513 PHONE (406) 841-2392 on (406) 841-2369 FAX (406} 841-2305 EMAIL: We}; WEBSITE: INDIVIDUAL EMPLOYEE REPORT FORM Please use this form in answering #12 and #13, and (cl) on page 5 Of the application for each employee and the person-inucharge of the program. Please make copies as needed and attach to application. Employee Name Kill-7? Position [trailcoc? 71w? a. Professional licenses held (active or inactive) at any time during the past ?ve (5) years. DATE OF LICENSE AND TYPE OF LICENSE STATE OF LICENSE EXPIRATEON 7' a 7 Wonm?k. 4d 770? (3/33/49? In. Has a licensing agency ever taken adverse or disciplinary action against your license(s)? If "yes" please attach agency documents ?led in the action including all complaints, initiating Yes No documents, orders, final orders, stipulations and consent and/or settlement agreements. c. - Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as a result of any of the following: having a complaint ?led against you; entering into a consent agreement with respect to your license as a result of a complaint during an investigation or during disciplinary proceedings. . Yes NO If "yes", attach a detailed expianation identifying each occasion, the date and the substance of the allegations, along with agency documents filed in the actlon including all complaints, initiating documents, orders, final orders, stipulations and consent andfor settlement agreements. cl. Has any legal or disciplinary action been filed against you, (including malpractice, etc)? If "yes", attach a detailed explanation of each instance including the date of the claim, name and Yes NO address of party complaining, name and address of forum or court where claim was ?ied,? docket or claim number and the substance of the allegations. . Sig nature MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL H, 0R OUTDOOR PROGRAMS 3?9 (301 PARK, 4TH FLOOR Delivery) PO Box 200513 Helena, Montana 59620-0513 PHONE (406) 341-2392 OR (406) 841*2369 FAX (406) 341-2305 EMAIL: dlibsdgag?mtgg? WEBSITE: INDIVIDUAL EMPLOYEE REPORT FORM Please use this form in answering #12 and #13, and {cl} on page 5 of the application for each employee and the person?in-charge Of the program. (Please make copies as needed and . . am a; Hm ,4 IL Position a. Professional licenses held (active or inactive) at any time during the past five (5) yearsl DATE OF LICENSE AND TYPE OF LICENSE STATE OF LICENSE EXPIRATION b. Has a licensing agency ever taken adverse or disciplinary action against your license(s)? If "yes" please attach agency documents ?ied in the action including all complaints, initiating YES LNG documents, orders, final orders, stipulations and consent and/or settlement agreements. c. - --Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as a result of any of the following: having a complaint ?led against you; entering into a consent agreement with respect to your license as a result of a complaint during an investigation or during disciplinary proceedings. Yes Kilo If "yes", attach a detailed explanation identifying each occasion, the date and the substance of the allegations, along with agency documents filed in the action including all complaints, initiating documents, orders, final orders, stipulations and mm audio:- set?ement'agreamants. d. Has any legal or disciplinary action been filed against you, (including malpractice, etc)? If "yes", attach a detailed explanation of each instance including the date Of the claim, name and Yes We address of party complaining, name and address Of forum or court where claim was filed,?docket or claim number and the substance Of the allegations. Will/limo {?nalised} Date Related experience; 1987-1993 Administrative Assistant for Wilderness Treatment Center. Duties included; Admissions of patients, office manager, typing dictation, telephones, filing, book keeping/record keeping, scheduling appointments, supervision of dietary and house cleaning staff. 1996~ present Administrative Assistant for Building Bridges, Inc. Screening admissions, parent and referent phone communication, maintaining student record, overseeing Academic Coordinator with public school and the student?s individual needs, developing and implementing weekly menu and food supplies, staff scheduling, dispensing medication to students, setting appointments for students medical needs, bookkeeping, payroll and also transportation. ?1 $5,229,5ng MONTANA BOARD or PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL oR PROGRAMS age (301 PARK, 4m FLOOR - Delivery) PO Box 200513 Helena, Montana 59620-0513 PHONE (.406) 841w2392 OR (406) 841-2369 FAX (406) 841-2305 EMAIL: WEBSITE: INDIVIDUAL EMPLOYEE REPORT PORN at Please use this form in answering #12 and #13, and on page 5 of the application for each employee and the person?in-charge of the program. _Piease make copies as needed and attach to application. . Employee Name ?j?ms Ema POSition nl?mbh Nb AVA ?fms a. Professional licenses held (active or inactive) at any time during the past five (5) years. DATE OF LICENSE Ann TYPE OF LICENSE STATE OF LICENSE EXPIRAHDN b. Has a licensing agency ever taken adverse or disciplinary action against your iicense(s)? If "yes" please attach agency documents filed in the action including all complaints, initiating Yes No documents, orders, final orders, stipulations and consent andfor settlement agreements. c. - -'Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as a result of any of the following: having a complaint filed against you; entering into a consent agreement with respect to your license as a result of a complaint during an investigation or during disciplinary proceedings. . Yes No If "yes", attach a detailed explanation identifying each occasion, the date and the substance . of the allegations, along with agency documents filed in the action including all complaints, initiating documents, orders, ?nal orders, stipulations and msent andlor settlement'agreements. d. Has any legal or disciplinary action been filed against you, {including malpractice, etc)? If "yes", attach a detailed ekplanation of each instance including the date of the claim, name and Yes NO address of party complaining, name and address of forum or court where claim was filed,? docket or claim number and the substance of the allegations. (?e/05 one Related experience: Six years experience working with troubled teens in a variety of roles, support staff, transportation, etc. Currently working toward a AA degree in Counseling with overall goal of achieving my license as an Addiction Counselor. Have completed one year successfully. MONTANA BOARD or PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL on OUTDOOR PROGRAMS page 7 ?f 7 (301 PARK, 4TH FLOOR - Delivery) . Po Box 200513 Helena, Montana 59620-0513 I PHONE (406) 841-2392 OR (406) 841?2369 FAX (406) EMAIL: li sci t. ov WEBSITE: INDIVIDUAL EMPLOYEE REPORT FORM Please use this form in answering #12 and #13, and on page 5 of the application for each employee and the person-in-charge of the program. Please make copies as needed and attach to application. Employee Name A?b?l 1 Position ?aws-Mic. a. Professional licenses held (active or inactive) at any time during the past five (5) years. DATE OF LICENSE AND TYPE OF LICENSE STATE OF LICENSE ACHVEIINACTIVEIEXPIRED EXPIRATION 0. Has a licensing agency ever taken adverse or disciplinary action against your Yes No If "yes" please attach agency documents filed in the action including all complaints, lnitlating documents, orders, final orders, stipulations and consent and [or settlement agreements. c. --Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as a result of any of the following: having a complaint ?led against you; entering into a consent agreement with respect to your license as a result of a complaint during an investigation or during disciplinary proceedings. Yes WNO If "yes", attach a detailed explanation identifying each occasion, the date and the substance of the allegations, along with agency documents ?led in the actlon including all complaints, initiating documents, orders, final orders, stipulations and consent and I or settlement'agreements. d. Has any legal or disciplinary action been filed against you, (including malpractice, etc)? If "yes". attach a detailed exnlana?on of each instance Including the date of the claim, name and Yes NO address of party complaining, name and address of forum or court where claim was filed,? docket or claim number and the substance of the allegations. 6:24 055 Signature Date . Relevant Experience I 21 months experience working with troubled teens; creating education plans designed to help recover lost time and credits and re?integrate them into the public school system as rapidly as possible. I Four yea rs experience as a technical trainer creating and implementing technical training to adults and teens. 0 Three yea rs counseling adults and teens in employment seeking skills resume writing, interview skills, letter writing, etc. 0 Two years tutoring high school and junior high school students.