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olorado OF'�Cp <br /> s y ent STATE OF COLORADO �� <br /> Procurement Registry * <br /> L11-:79rucow Irsiwss 187 <br /> The State of Colorado,through its Department of Regulatory Agencies,maintains a master list of firms interested in doing business <br /> with the state. The list is posted on our web site for use by State employees and the public. By completing this form and returning <br /> it,your firm will be registered on that list. In order to process the form,we do need information about the type of work your <br /> company performs and a Federal Employer Identification number for your company or Social Security Number if you are an <br /> individual or sole proprietor.This number will not be posted on the web. Questions about the registry should be directed to(303) <br /> 894-2355. Please return the completed form and requested documents to: <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): <br /> 2. Legal Name of Business <br /> List dba, if any <br /> 3. Mailing address State Zip+4 <br /> 4. Business phone Fax <br /> 5. E-mail address Web address <br /> 6. Name of Contact Person: Last First <br /> 7. Type of work the company performs(Use SIC codes found at www.osha.gov/oshstats/sicser.html) <br /> 8. Ownership information (use additional pages if necessary): <br /> LAST NAME FIRST NAME MIDDLE % OWNED G4NDEE ETHNICITY <br /> INITIAL (S (SEE** <br /> BELOW <br /> Gender/Type codes * Male ...................M Ethnicity codes ** <br /> Female .................F Asian Pacific.... AP ............. HI <br /> Owned by Tribe...... T Black ............ BL spanic).. WH <br /> Publicl held ... .....P Native American ...NA ............OT <br /> 9. Is your company registered on the BIDS system or in the process of becoming registered? Y❑ N❑ <br /> Signature <br /> Title Date <br /> Visit these web sites for information on BIDS:www-assa.state.co.us;DBE Certification: www.dora.state co.us/Certification <br />