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OF"COl0 <br /> olorado <br /> rocurement STATE OF COLORADO 0� <br /> * �O\ <br /> egistry \ <br /> Procurement Registry <br /> �* <br /> n� 876 <br /> for Colorado Business <br /> [anl Supp'R Servvo CaMx+,b INflQMCMI&enan <br /> Agencies,in a master list of firms that may be used in the State's <br /> The State of Colorado,through its Department of Regulatory ho <br /> discretionary procurement process. The list is posted on our web site s r use by our firm l St be employ registered on that lkst pIf thissforming ecisions. <br /> is <br /> By completing this form and returning it with the requested do yur firm may our <br /> be registered. Questions about the registry should be <br /> returned incomplete or without the supporting documentsfeted form andand requested documents to: <br /> directed to(303)894-2355. Please return the comp <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 Zip+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. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htrn) <br /> 7. Ownership information (use additional pages if necessary): o� & GENDERfI Y'E 1~![NiC1TY <br /> ���f����,,�� s �.:s� "p' ; "rF�'�`�'•,..,�.,�,� FiirSTNAME 7 �' � � � `z INrIt1L Iw .`„,` kr , � �#$Et,C►W}, .{�•s BELOW)'?, <br /> Gender/TYPCcodes Male ian acifcc APB c <br /> �a ��� r u fi a s F f Itef IIOri HispantC) WH <br /> �'�: � �P:ubliclyhead. � P `���"'� � Nat►ve.4mencan D <br /> 8. Is your company registered on the BIDS system? Y❑ ND• <br /> Title <br /> Date <br /> Signature <br /> Vicit these web sites for information on BIDS:www.Qssa.state.co.us;DBE Certification:www•dora.state.co.us/Certification <br /> 11 <br />