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olorad0 ���F,C lO\ <br /> rocurement STATE OF COLORADO <br /> egistry (� Q <br /> Procurement Registry <br /> LffnIb.-- for Colorado Rosiness \ 1876 <br /> c jsuuM.4w xn cowraJn onarM ccnancmn� ' <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 ,�,, n I <br /> 1. Legal Name of Business g�Ss)e� �� la�a� <br /> 4/ + � * � �� FEIN �� �y—�� <br /> List dba,if any <br /> 2. Mailing address `t L4 d i l r C)� <br /> Ul' l�UQ ��_ State Zip+4 g I aL `7 <br /> City n / I /� - rj /\ <br /> 3. Business phone /Q — �`'�—`y � Fax /�T�� C X 4— 43V <br /> 4. E-mail address Web address <br /> ]�P��� 1 <br /> 5. Name of Contact person: Last r ► � 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 /> Laszxnt � 1k � Fmsrrtaat x (sue*aEzow} :s *.! > ow) <br /> zrrrtztit. <br /> a <br /> was <br /> J bo 0/0 YY1 <br /> tty `lvi x)E'itItOlCt �COde3 x* z t <br /> 'Giender/T�codes- ;We" <br /> rubu�ly held ....., P *1A <br /> Native American ��_...... . <br /> 8. Is your company registered on the BIDS system? YJ] NO• <br /> Title Date <br /> Signature 47 n <br /> vicit these web sites for information on BIDS:www.assa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />