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1 <br /> oloradu /ti OF•,Cp Q <br /> ' rocurement <br /> egistry STATE OF COLORADO <br /> Procurement Registry r' <br /> f<iL for Colorado Business <br /> (;euxal wpportSmm Gslnerfocxked Cerbiw�mm <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 /> be registered. Questions about the registry should be directed to <br /> incomplete or without the supporting documents your firm may not <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 ,1 <br /> 1. Legal Na <br /> me of Business FEIN <br /> List dba, if any <br /> 2. Mailing address Snyw U <br /> Cit Y 1 f'L�dQ� State Zip+4 g �- <br /> 3. Business phone�_L�Ig`v— 24 Fa <br /> / 1 rn l yer r Web addres <br /> � <br /> 4. E-mail address ���- t ' <br /> 14) <br /> 5. Name of Contact person: Las r First <br /> h IC <br /> of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm) r]q <br /> 6. Type P y P <br /> 7 Ownership information (use additional pages if necessary) <br /> MIDtxEawrtEv trENAEI21'1"1'RE ET3NtCTfY <br /> )'IE2SEIF1�IVtEz 3 s r a x ## <br /> BLAST NAME .� 1 <br /> eah <br /> f 1 '3J <br /> A ��Gea nder>rFYpe codes * MaIey M ��s Ethiucity codes�`�� p � x� ��F '� � � HT <br /> a;�s r � <br /> g lYetnale 1 ASta[t PaCiIC A� °Hl$�Iar1Sc <br /> T _ x Black BL W1ute(ntin Htspatu <br /> y Mp,s y s (}WI1Cd 1>Y gibe a a - r s <br /> P <br /> � Putlicl held...•,......, r•- ' <br /> Native Ariterican <br /> 8. Is your company registered on the BIDS system? Y❑ NET-"' <br /> 9. To verify gender and ethnicity,submit a copy of one of the following for each owner: birth certificate,CrierZIlic:en:se:� pas ort, <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 leg ucture: For <br /> sole proprietorships—a trade name reg�istration or schedule C;For partnerships,LLCs,or S corporations chedule K. from <br /> your firm's fed come tax returns <br /> for Corporations page#2 from the corporate tax returns.If the firm is Aj8(a) <br /> certified mit a y of the letter of�''acce e. <br /> Signatut <br /> Title d Date r'( 13 <br /> Visit these web sites for information on BIDS:www.Rssa.state.ca,us:DBE Certification:www Born ctotr <br /> III <br />