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Re?neWSuPpxt5W4k" cQbr. Ufrw4CWd&Vjcn <br />STATE OF COLORADO <br />Procurement Registry <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 _ <br />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 />i <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 />I,PAS?rN?AME T ikS fNAME MIDI)LT ? <br />]NMAI, °??04VNtiD 1Fh <br />{SEE* BELOW) FlHti1CCIY" <br />(SuP Iii 1.011') <br /> <br /> <br /> <br /> <br />Gender/Type codes ' Male .__........._ M <br />Female ................ F <br />f?wved b%1 Iiibe ..._....[" <br />i'ubliclv held ... Y Tthnicitr codes -'+ <br />Asian ll?icific .... Al Hispanic ......... ....... HI <br />- Black BL NVhitc (pon-Hispanic) .. lk?li <br />Native American ... NA Othei ...... ...:........ O"1 <br />8. Is your company registered on the BIDS system? YEI <br />NE]. <br />Signature „ Title Date <br />Visit these web sites for information on BIDS: www.Rssa.state.co.us; DBE Certification: www.dora.state.co.us/Certification <br />olorado <br />mcurement <br />egistry