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t <br /> olorado Coz, <br /> rocurement <br /> egistry STATE OF COLORADO <br /> Procurement Registry <br /> �T!• for Colorado Business *18 76 <br /> C MSgpn`+rvkas Co1o.d.01ft (Cni(Irtrrn <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 /> ,qgLASTX3AME ' ' ' FIRSTP[AME ft <br /> MIDDLE %oWt�rED '� GENT? ETFrNICrrY E <br /> z � <br /> e f.(SE AEQW} (SEE**BELdW} <br /> v <br /> '�- <br /> 41 <br /> YP <br /> a„ ra Female Fa �. SranaCrfiC �spaivG ° aHI. <br /> �fr� *� Owned by Tnbe�-� T �*� �Y EB1aGk F� �'� � BL '� 1�hite tYon Htspatuc) WH <br /> 8. Is your company registered on the BIDS system? YF� NF�. <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 />