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olorado ipF CpZ <br /> rocurement <br /> egistry STATE OF COLORADO <br /> Procurement Registry <br /> frB� {er Colorado BasMess 1876 <br /> e;ane.ai�ppon5v...� c�.,aoaerdcmeov� <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 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 /> ;?c <br /> :ype �#ltrtlei�l�ettdes <br /> "'^ ,''nyX e� i"y' 3ryi �+,►}+p+a,.y � ^' ""�r j aetICa.• � � �'� Rig, w.w.,�wz x,,; <br /> �W�.te�,my <br /> �°,y✓.i.. ,. �F.t, . '�`�v s�.�; :��� ,.. .tl7�ri ,lileld.«::w<.y�1SA .:.,_,�'{>�� ��.N.a�YC=A�tC:�� �LL��".�."r aw� a„.�, ��.'y.,.. „`�'�.. <br /> 8. Is your company registered on the BIDS system? Y❑ N❑ <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 Date <br /> Visit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />