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JiOrado <br /> [OCurernent <br /> ' e?istr? <br /> <br />¦T? <br />for Colorado Business <br />C nTrl Supp+t?m'Kee CUEIf.11M ?11HR??G'M1?Ikadun <br />STATE OF COLORADO <br />istry <br />Procurement Reg <br />25 <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 />FEIN <br />1. Legal Name of Business ke d - <br />List dba, if any <br />2. Mailing address ?Q <br />v O (9©x 11? q? <br />#0 State CCU Zip + 4 <br />City <br />8120-X72-2112.3 Fax 9?0 9?a-21122 <br />3. Business phone <br />4. E-mail address ?? lc X ® ad / 60h7 Web address <br />5. Name of Contact person: Last cX?rea First ?i rnPl <br />6. Type of work the company performs (use sic codes found at www.dora.state.us/Certification/si ??>/a?FL? co/iv: <br />7. Ownership information (use additional pages if necessary): <br />imnt % awri -- ?G?rrv ?I` E?itcrtY <br />Fi st*Ynr <br />LAsTNA Iv <br />/00 12) <br />Gender/Type codes '-? Mal <br />AP' Hispanic Hl <br />Female ?F r Asian Pacific <br />Black ?L White (non=H?spamc) WH <br />Owned by Tribe = T - <br />.I3attti e "American : NA Other . <br />:Ppblicly"held .:" ........ P° <br />8. Is your company registered on the BIDS system? Y5r NF?• <br />S <br />Title <br /> <br />'Date CF- 30 <br />vicit these weh sites for information on BIDS: wv w.essa.state.co.us; DBE Certification: www.dora.state.co.us/Certification