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olorado oF'COl <br /> 0 <br /> %ct�ment STATE OF COLORADO yQw 10 <br /> Procurement Registry <br /> knnAb— for Colorado Business 8 7 <br /> Ca011WPpwtSff&" Culma&OfllaNC0Ufiwtlnn <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 Charles W. Sickles Construction FEIN 84-1439993 <br /> List dba,if any <br /> 2. Mailing address P.O. Box 91 <br /> City Hotchkiss State CO Zip+4 81419 <br /> 3. Businessphone ( 970 ) 872-4889 Fax (970) 872-4890 <br /> 4. E-mail address Web address <br /> 5. Name of Contact person: Last Sickles First Charles <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm) Excavation <br /> 7. Ownership information (use-additional pages if necessary): <br /> x gw 014,a U <br /> Sickles Charles W 100% M WH <br /> K <br /> 8. Is your company registered on the BIDS system? Y® NM. <br /> Signature Title Owner Date 9/1 3/9 9 <br /> Visit these web sites for information on BIDS:www.assa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br /> I� <br />