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olorado Of'COro= l <br /> egistr went STATE OF COLORADO <br /> gistry <br /> Procurement Registry <br /> LWT146- for Cawodo Balmss1876 <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 returned <br /> incomplete or without the supporting documents your firm may not be registered. Questions about the registry should be directed to <br /> (303)894-2355. Please return the completed form and requested documents to: <br /> Division of Minerals and Geology <br /> 1313 Sherman St.,Rm. 215,Denver,CO 80203 <br /> 1. Legal Name of Business C & K OF FOUNTAIN, INC FEIN 84-0956340 <br /> List dba,if any <br /> 2. Mailing address PO BOX 571 <br /> City FOUNTAIN State CO Zip+4 80817-0571 <br /> 3. Business phone (719) 382-8551 Fax (719) 382-8700 <br /> 4. E-mail address CKFOUNTAIN@AOL.COM Web address N/A <br /> 5. Name of Contact person: Last 'LACEY First KEN <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm)161,162,1629,1794 <br /> 7. Ownership information (use additional pages if necessary): <br /> i.i -Eyfi'S d 9 i <br /> LACEY MARY K 51% F HI <br /> LACEY KENNITH L 49% M WH <br /> � eaclerodes + dale.: �� I1'C E nodesRon ni <br /> `.�. ,u2'w � ��t <br /> ","� <br /> � �q��p K �ttClfAWAy�RL <br /> •r .cy`�.� �, a ,s ., s z�ate'^ -.R ,,,,; �. �zr� <br /> �,� . '��� �;. ��:.. ��z �Pttb1"tc..:�i�elil....w�:�> �'��< ��m,����.;�vt;tA�rtcan:.DNA r� ��t��r•.� .� <br /> 8. Is your company registered on the BIDS system? YEI ND <br /> 9. To verify gender and ethnicity,submit a copy of one of the following for each owner: birth certificate,driver's license,passport, <br /> or certification of naturalization. If the firm is SBA 8(a)certified submit a copy of the letter of acceptance. <br /> 10. To verify ownership submit a copy from the following list of acceptable documents based on the company's legal structure: For <br /> sole proprietorships—a trade name registration or schedule C;For partnerships,LLCs,or S corporations—schedule K-1 from <br /> your firm's federal income tax returns;and for Corporations page#2 from the corporate tax returns.If the firm is SBA 8(a) <br /> certified submit a copy of the letter of acceptance. <br /> Signature Title PRESIDENT Date 14 JUNE 99 <br /> Visit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dom.state.co.us/Cectification <br />