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oiorado <br /> Or CCQ� <br /> r°`urement STATE OF COLOR-ADO <br /> egistr✓ G,. <br /> C li <br /> Procurement Registry <br /> for Colorado Business \ 18 76 <br /> (�Y,��,,,,, WIuo�11111flR�C.nIlkJron <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 30203 <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 /> r MI1?DLE �%OWNFD� GENDETf�I1CT15Cx <br /> LASTNA1v1E <br /> z 1s � <br /> ww x z eFIRSfAME� T°3 ' r� S cC# � (sEE* EY ow <br /> t� ,ti yYa�..2�.S+.a!"roBf .�w�,z <br /> AiA <br /> Gender/Type codes '-Male M Ethnicity code§** + �; ' <br /> yrax ? Ma rw a," t tir n� tall pSCiftC t attic <br /> S <br /> .z a.::;hti n c r e '.. ,� wr y, ;,ram ran�.r,.� ,1^. f a q..s "r "^� t „„^t ,'.✓ �^�," '+ Wlllte non I�1 aR3C WH <br /> OyvvedbyTnbeT <br /> _Publicl "held t ...P. " 'Native Araencan ,.NA:, " ,Other <br /> 8. is your company registered on the BIDS system? YF� N[). <br /> Signature <br /> Title Date <br /> visit theee web sites for information on BIDS:www.ossa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br /> 3� <br />