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olorado �pF COl <br /> cu rorement ,_Off, <br /> egistry STATE OF COLORADO yam % \901 <br /> Procurement Registry <br /> fT1� for Colorado Business <br /> The State of Colorado,through its Department of Regulatory Agencies,maintains a master list of firms that may be used in the State's <br /> discretionary procurement process. The list is posted on our web site for use by all State employees who make purchasing decisions. <br /> By completing this form and returning it with the requested documents,your firm will be registered on that list. If this form is returned <br /> incomplete or without the supporting documents your firm may not be registered. Questions about the registry should be directed to <br /> (303)894-2355. Please return the completed form and requested documents to: <br /> Division of Minerals and Geology <br /> 1313 Sherman St.,Rm. 215,Denver,CO 80203 <br /> 1. Legal Name of Business FEIN <br /> List dba,if any <br /> 2. Mailing address <br /> City State Zip+4 <br /> 3. Business phone Fax <br /> 4. E-mail address Web address <br /> 5. Name of Contact person: Last First <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm) <br /> i <br /> 7. Ownership information (use additional pages if necessary): <br /> P <br /> Y h <br /> ',� s s�x� 1-�� "�-�•� �?n: pea` �y� � z .�ed'za�'y� 'erg°'sr .,,a'� .�; �j,E,a 1D gw C7��� <br /> ����° �S�r�.�k?`^'�`3s.L r� � � �z� n ,� �s�r� ''t��� v� as 3 ; e�x�'I �� .� � �' . p�+� '•a�e, ,�'�c.r. ��+•.,; �fa��`.�a T.�?. <br /> ..; ">.. `v ...Y' 'sue ,✓i ..". �:.. �.'dr ' R.��...s'r��;�»: ,. ��29 '�3;fs"s'' �:u�•.:i (SEI:*��W"� ��,Li-i�3��Fi�V:R F <br /> h •��. ,. `�`a,,°�` � .a z�'� P. e`i�� ��' � "�*�n� � '� �' �3�'a 's'-k"j '° �s �?'"h A'' �,. R` �'e, � f �, �s� <br /> ,���������.-���� x. ., >: �� s Public `�tteld.z� ,,..,..,:ly� ��`=a. �.. N�t•1V�;AlneriC8t1�,f,1�it4 t��Q � �DT <br /> 8. Is your company registered on the BIDS system? Y❑ NO <br /> 9. To verify gender and ethnicity,submit a copy of one of the following for each owner: birth certificate,driver'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 legal structure: For <br /> sole proprietorships—a trade name registration or schedule C;For partnerships,LLCs,or S corporations—schedule K-1 from <br /> your firm's federal income tax returns;and for Corporations page#2 from the corporate tax returns.If the firm is SBA 8(a) <br /> certified submit a copy of the letter of acceptance. <br /> Signature Title Date <br /> Visit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />