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ilcrada <br /> ST TE Ur COLO1AD0 <br /> Procurement Re-,istrti <br /> l -e Siat', of(:ol„radu, through Its Depa^meat of P_2,_,lator-i maintain; a C ast�..- iist of <br /> state. Tne list Is posted on our web site :or use by Siate empioyees and tie public. E y c,)mL etln2 ta: tor-m 'J�� lyiness <br /> It, your t:rm will be registered on that list. In orrer w <br /> to process the form, e do need information atout the <br /> ' - V <br /> r,pe of wer;your <br /> company performs and a Federal Employer Identirication numcer for your ccmcan•i or Social Securri Nu 'tuber if ieu are an <br /> indr"idual or sole proprietor This number will not be posted on the web. Questicns accut the re2:stri should be dtrec;ed <br /> 39'-2'3 5. Please return the completed form and requested documents to: o <br /> Division of Purchasing <br /> 225 East 16th Avenue, Suite 900 <br /> Denver, CO 80203 <br /> 1. Federal Employer Identification Number or Social Security Number(Required): `=! -1 �i U ; <br /> 2. Legal Name of Business C) '„ <br /> List dba, if any <br /> 3. iyfailing address l 1` I I ��:(,y� -�rY r' i <br /> State C-C Zip+4 <br /> 4. Business phone �� ' ��7` -uC,'Q I Fax <br /> 5. E-mail address Web address <br /> 6. Name of Contact Person: Last �C� First !'V r',,, <br /> Type of work the company performs(Use SIC codes found at www.osha.2ov/oshstats/sicser html) <br /> 8. Ownership information (use additional pages if necessary): <br /> L �y� F IRbZ NAME MIDDLE % Ow`!ED GENDER/TYPE ETiLmcm <br /> LNTn-kL (SEE*BELOW) (SEE** <br /> BELOW) <br /> tC1 IN k <br /> F Jii� <br /> Gender/Type codes * Male ................... �( Ethnicity codes *• <br /> Female ................. F Asian Pacific .... AP Hispanic ............... ... HI <br /> Owned by Tribe ..... T Black ............ BL White(non-Hisoaric).. W1-I <br /> Publicly held ... .... P Native Arne^can ...NIA Other ......0............. OT <br /> 9. Is your company registered on the BIDS system or in the process of becoming registered? Y❑ <br /> Signature�t 't`i t'( I�c �. �i- i i Title 1«� Date, <br /> Visit these web site's for infornation on BIDS: wv v%v 2ssa state co us: DRF. Prof r�tinn <br />