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(7il�.r:iuq . <br /> 10cwealent C <br /> e�isrr� STATE OF COLORADO <br /> Procurement Registry <br /> !'—a for CAI«ado 2usiness 4K <br /> Tne Statc of Colorado, through its Department of Re20la[or/agencies. maintains a„aster list of i:rrs that may be use+ ;n the SCa[e', <br /> discretionary procurement process. The list is posted or, our web site for use by all State emplovees Xho make purchasinlT decisions. <br /> By complctino this form and returning it with the requested documents; year firm w li be registered on that list. If this form is returned <br /> incomplete or without the supporting documents your firm may not be re�zistered. Questions about the registry should be directed to <br /> (30 ) 394-2355. Please return the completed form and requested documents to: <br /> Division of Minerals and Geolovi <br /> 1313 Sherman St., Rm. 215, Denver,CO 80203 <br /> 1. Le-al Name of Business SIN ?4_ iaa c-) <br /> List dba, if any <br /> 2. Mailing address g U) <br /> ,� v <br /> City Jr I(Udall' State Zip+4 0 R, 01- <br /> 3. Business phone Fairq� Qp <br /> 4. E-mail address �Y2rn, t� r Web addres /1 <br /> 5. Name of Contact person: Last _'1r)Lb1_P_r First <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htrn)llG `i � <br /> 7. Ownership information (use additional pages if necessary): <br /> I.ASiAME. aF s k u FBLST NAME ET <br /> MIDtSt E %QW`IED Ci'r1`IDEK/ 'P£ HNTCIiY <br /> fs <br /> IV <br /> _H" <br /> �r _30 <br /> ' GenderlType codes * Mate M. Ethruatp codes x: 777 <br /> Asian Pacific AP i 1•I13PaIIIC .: <br /> y w Owned b}+Tnbe T re a Black 4Vfu to(nan Hlspamc) W K. <br /> BL <br /> ~` Publicly held dv Nae American.. :NA <br /> .< . ......... <br /> ......... .........OT. <br /> 8. Is your company registered on the BIDS system? Y7 NIT," <br /> 9. To verify gender and ethnicity,submit a copy of one of the following for each owner: birth certificate, river's license passport. <br /> or certification of naturalization. If the firm is SBA 8(a)certified submit a copy of the letter of acceptance. <br /> 10. To verify ownership submit a copy from the following list of acceptable documents based on the company's legaLstructure: For <br /> sole proprietorships—a trade name registration or schedule C;For partnerships, LLCs ,or S corporations chedule k-1 from <br /> your firm's fed come tax returns; nd for Corporations page#2 from the corporate tax returns. If the firm is 8(a) <br /> certified mit a y of the letter o�f✓aece e. <br /> Signatur Title Q <br /> '� Date 11 i3 <br />