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olorad0 <br /> rocurement STATE OF COLORADO <br /> egistry <br /> Procurement Registry * . <br /> 1876 <br /> L4— for Colorado Business <br /> GtMTJI SUppiM`u'xn CU�J'k'IIINQd ICnIIkJMU <br /> at may be used in the <br /> h its Department of Regulatory Agencies,maintains a master listo employees whohmake purchasing decisions <br /> The State of Colorado,throug P <br /> discretionary procurement process. The list is posted on our web site for our firm will be registered on that list. If this form is <br /> By completing this form and returning it with the requested documents,your <br /> be registered. Questions about the registry should be <br /> returned incomplete or without the supporting documents your firm may g <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 <br /> List dba,if any <br /> 2. Mailing address <br /> State _._ Z1P+4 <br /> City <br /> Fax <br /> 3. Business phone <br /> Web address <br /> 4. E-mail address <br /> First <br /> 5. Name of Contact person: Last <br /> 6. T e of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htm) <br /> YP <br /> 7. Ownership informatton (use additional pages if necessary) In o G1DEItE ETH�IIC1TY <br /> a � � (5 ..,x BELOW} <br /> a .u, <br /> M Ethnuttycodes,� z <br /> � 2U11� #_ �����» � r�� �� ���+QWned�bY Titbe� �� ��, ,� �' � �'• ` "` �"�1�T[���. �� , <br /> 8. 'Is your company registered on the BIDS system? Y❑ Nn• <br /> Date <br /> Title <br /> Signature <br /> us/Certification <br /> visit these web sites for information on BIDS:ww Cssa.state.co.us;DBE Certification:www•dora.state.co. <br /> w <br />