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' oiorado 0-�, C'-p=l <br /> rocurement ti <br /> ' egistr✓ STATE OF COLORADOT ��, <br /> Procurement RegistryLl <br /> rf� j for Colorado Business \' � <br /> CM•I wpp,�ktrxn Culurwk.Vn1Q�G.nitkemn �876 <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 <br /> returned incomplete or without the supporting documents your firm may not be registered. Questions about the registry should be <br /> directed to(303) 894-2355. Please return the completed form and requested documents to: <br /> Division of Minerals and Geology <br /> 1313 Sherman St., Rm.215 <br /> 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 /> 7. Ownership information (use additional pages if necessary): <br /> LAST NAME ' a a r 3IRST j1AME, "� e hN IVIII?DLE /o OV✓NEDr7Ef1AETf�IIC1Tt� <br /> k-II <br /> n,.�. r �,2,. xay,a ($�,+^�,B w �. .t✓AELOW). <br /> Gender. ,vpe codes 'Male aM Ethntclty;codes <br /> � i a�t•�,��°'�.�"ze.i "�'".^t�' "�' g +!"FCIIlaIC`a"�,•. "ar "s�"tF� `�-,ia�"`�` �A513IIaP8CIfC �o '" ����C r' rHI`: <br /> '> s ed by"`r ibe`N"V ;T` Btack 4 BE: �' Wlvte[non Hisgazuc}y" WH <br /> r: p Publicly held P j 'Native Ameiican "DNA ;Otherw r x QT. <br /> 8. Is your company registered on the BIDS system? Yr_j NF�. <br /> Signature Title Date <br /> visit these web sites for information'on BIDS:wNm.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />