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04 Co�\ <br /> olorado <br /> rocurement STATE OF CO- ORADO ' 9 <br /> egistry yQ/ o, <br /> Procurement Registry *) <br /> for Colorado Business <br /> \\ 1876/ <br /> Ccncr�I Supp+n 4rrico CaWtaM.lNfla MCcmfkamn <br /> aintains a master list of <br /> s that may be used <br /> the <br /> The State of Colorado,through its Department of Regulatoryweb site for nuse by all State employees who make purchasingndecisions. <br /> s <br /> discretionary procurement process. The list is posted on our <br /> By completing this form and returning it with the requ rit <br /> returned incomplete or without the supporting documents <br /> firmme may not bnts,your e egisteted.will be ebQuestions about istered on that tthe registry should be <br /> feted form and requested documents to: <br /> directed to(303)894-2355. Please return the comp <br /> Division of Minerals and Geology <br /> 1313 Sherman St.,Rm.215 <br /> Denver,CO 80203 <br /> FEIN <br /> 1. Legal Name of Business <br /> List dba, if any <br /> 2. Mailing address <br /> State _ Zip+4 <br /> City <br /> Fax <br /> 3. Business phone <br /> Web address <br /> 4. E-mail address <br /> First <br /> 5. Name of Contact person: Last <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm) <br /> 7. Ownership information (use additional pages if necessary) Eta <br /> G Exlt�'rsncmc , <br /> tea,, * .,�. �, ``„�•�M _'��:EtIiDMCity COdeS.^:, � � ,; � � � �_�H'���.��y��Cx "�°A'� � � HI. <br /> �icI1dBC�}'�e COd 1a $18n�8ttaiG AI'r "K_" <br /> � ,wag. G�q,�'s�.pw�:9x � � �� '�� "•s�` '� 5.+�.:�-��` '�' ,r, i°. , ,� ». ag�x°" .-,.�'•� l x- � <br /> 8. Is your company registered on the BIDS system? Y❑ NR. <br /> Title Date <br /> Signature <br /> BIDS:www.Qssa.state.co.us;DBE Certification:MM domstate.co.us/Certification <br /> v;cit these web sites for information on <br />