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EP 06 '95 11:43RM DIV/MINERALS&GEOLOGY <br />~9~: : ' ~ xr~>I~'Cr~a <br />KLH - ITS, Inc. <br />rnede Name <br />KLH Engineering of Grand Junction, Ine.' <br />ao.a.aretxrrrnovc a[/sa~u.asaaet~l Name chan a in rocess. <br />AQailioE.4dMrss 2516 Foresight Circle, Suite 9 <br />~SKState,7tlp, Grand" Junction, CO 81505 - <br />Rtyuit Address - Optiatul <br />CSry, State. tip. <br />Order Address -Optional <br />Cdy, StaeF Tap. <br />lYpe at[d rata <br />Nm[16et @i= <br />Number (TB'i) blow: <br />indavidaal (Iadivitfual'c SSN) <br />norea~.~.ra+.a~.w~..r~.ra..,r.~r...sr.~m..o.e a..:tmerra.ra. rs~r~-~- ~- -~-- <br />Sale Proprietorship (Ownea't SSN a Susinrss FEIN) <br />l a1rg: g+.d Ori ~e a.a,f. aIIl.d as YwP ®i (CI~+ K..~e, b erne ry <br />SSN _ _ <br />F..~ - <br />Par~ship _ ^Crearzal ^Limited <br /> <br />U Estate/1~t (I,egeIF.+16tY'sFlN) <br />Naf&b~l~wi`'•-•~-_- ~nfne/w.,V.q.m.odsw~ra ~lu4kp n'f9 ud/i.a~djs~r~e - <br />.mr~MSC[ia~sddcs4.s LaK lctlrr.cobrµ.,~, b.~ --_ __--_--- <br />OO,Q Qtrorgn of Iadividnals (Eauty's EIN) _ <br />® Carpora4aa Do you provide medical txrvias? ^ Yes ~No (Corp.'s F1N) 8 4 - 0 6 8 2 6 9 0 <br />U Go+anmeat(a'GovernmrntOpetatod)F.ntity (Enuty~sF.IN) ----------- <br />Ot~mtioa ~rempt from 4LIC under Stxtlou 501(a) i ' (Org's FIN) _ . <br />.Ibyouptovidemedicai~servitxs? ^Yes ^No -- ---- -- <br />(deck Here dyt>,t do atx have a SSN to EIN, but have applied for ono Stx reverse for infarrrratitw on How ro Obtain A 77N. <br />I.ic~nsed Real F.Snte Broker? ^ Ya ^ No <br />U,dx ['wlsss OrP~Y. i atcy are <br />(1) The ssumbef listed on Nis [am is tey ceaua Tupayer Identirinr:on Nundrr (err I Ito .waiting for a number to be ifaued m me) AND <br />C4 1 am o01 fnbjxt b bad7rp rittdnlditg beuute: (a) i am eran(x r,pm baditp .riddaMding. err (b)1 have not been..d)Ged by the Lua,vl R,eveuue Service (IRS) <br />Nos 1 rYa tabjo4 b EaCI]op vith[nldivg u a result of a failure [o repot all iere7Ct ardivrde.ds' or (e) dse IRS 4as rowed or eel l a'o no longer subjm to bckup <br />(dbrs notspply b 1W wore baaoctiant, smtgaec imnut Pid. dX atgaiatim dabaodonmrnt o(SxutM ptupetry,mebibe[ien b an is,~ividid <br />setuaeet o0aail®r~t (~N. and pgsoen[s attri[Ma useiz,aard Csridrnds). <br />mtrtr7rw•noN tNSIxVC[IONS -Yoe toast aoo our (ran w •bo.v iryoo have beo...odred by ds ms dw yon are casseouy subf eat b backup w:ddgldint <br />6c~,.x er,eoder reporting in~aeA err dividends on your las eyntn. (Sec Sig..(ng Ne tuufir~don on the reverse of Nis fora) <br />NAME(Prird tr7ype) Linda R. Stockton 717LE (Prinra~y~e) Admin. Ass' t <br />atrmoR¢En stcrrnruRe ~ DnTE 916 ! 9 5 rllDNS ( 9 7 0 > ~4~8? SS <br />00 NOT WRJ['fE BEI.o THIS LINE RETURN BOTH COPIES r0 ADDRESS ABOVE <br />AGENCY USfi ONLY <br />A6rncy _ MPOVed By -~ <br />IOyq Y- N_ <br />VEND Add:+lon _ Qeoe<~ Aclian Coe>olele0 By <br />]9S534J~la66IQ 1096) <br />P.3i4 <br />STATE OF COIOfiADO <br />t)FPAR7M17tTOFNA7URALRF90URr.ES <br />DNISION OF MINERALS d GEOLGGY <br />215 CENTENNIAL BUILDING <br />1313 S}IERMAN STREET <br />DT3IYER,COLARA00 80203 <br />Sl1300000 <br />'F <br />SEP p 7 1995 I Attn:'QeboCAh:L- Mulloy <br />Division of Min6rdlS 5 <br />Dme <br />n. <br />