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olorado <br /> ' rocurement <br /> ' egistr? <br />Ll <br />J <br />gTa for Coiorodo Business <br />C ntM SUpp+ltmn CulurxM?Jlrlv.?C.nukeron <br />STATE OF COLORADO <br />Procurement registry <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 RLI?-D9go1 <br />1. Legal Name of Business ?'??? A t I <br />List dba, if any <br />2. Mailing address A315 -I C? I too <br />??ArU ? A <br />city <br />3. Business phone 6)63 ? ° 3 519 <br />4. E-mail address X55 ?tN C AFrE?+ ??? <br />5. Name of Contact person: Last ??V 6 First C,I UL <br />6. Type of work the company performs (use sic codes found at www.dora.state.us/Certification/sic.htm) +a Ft?V ffV <br />7. Ownership information (use additional pages if necessary): <br />'" MIADT E % O V ED <br />LASTN4ME FIRsrNn4tF - _ CiENDE3L'TYP EGTtY ; - <br />i'_L?., (SFE*BFI, W? .($EE LBEL6W) <br />INIITAI, <br />M <br />' Gender/lype codes ' Male Ethnrc;ty codes,*? - - <br />Female = F Asian Pactfic AP ?Pc= <br />t 'pwn TnTse, . T White'?non Fhsparuc) WH <br />edby )31ack ..-. BI,. <br />Publicly -held .. 'Native American `:3vA Qthgr_....... OT <br />P <br />8. Is your company registered on the BIDS system? Y[] <br />Title P Q,e-5 <br />State C 0 Zip + 4 <br />Fax (5 7- 3,?,s` <br />Web address <br />Date <br />visit these web sites for information on BIDS: wltiw.sssa.state.co.us; DBE Certification: w v.dorastate.co.us/Certification <br />11