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OF'COl <br /> olorado `\ <br /> rocurement - —0� <br /> egistry STATE OF COLORADO N�j ,90\ <br /> Procurement RegistryLffT1ftAhk.__ * *) <br /> for Colorado Business <br /> Cm js,p�--Av CoYa+Jn LNM¢MCcnllkrtWn <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 <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 <br /> First <br /> 6. Type of work the company performs(use sic codes found at www.dora.state.us/Certification/sic.htin) <br /> 7 Ownership information (use additional pages if necessary) <br /> MIDDI E %OWNED a GEjII?FR/TY1'E ErHNiGTIY <br /> # f 1 IlLSTPtAMF+777T <br /> LAST;NAhE <br /> 51 <br /> * M )C4t�iDlGt aC9Jes +tu 4 r HI <br /> e six h Cs'fiderflype codCSx a1C r 1C <br /> 1�51�Si i if[C <br /> 8. is your company registered on the BIDS system? Y❑ NF. <br /> Signature <br /> Title Date <br /> vicit these web sites for information on BIDS:www.assa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />