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olorado � O`..l <br /> ' rocurement 4;___: <br /> egistry STATE OF COL.ORADO <br /> Procurement Registry t <br /> RI• for Colorado easiness 1876 <br /> 1c <br /> C nenl Suppnn mwn ColutaiM,INflQ M C nllkaoun <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. <br /> 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 First <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 /> 3:ASTNAIVIIrY '"• :"-_` _ - t' `NEDLE oa.ONNID �GFN7D_ XTHNICiTY'^ ; <br /> "sr • "+ s c..IN1 SEES W �Sff gBFI OW� <br /> a *, Geoder'/Type codesr' ale.;; Ethnicity codes"** =" ,.. t: *�,:=y r• <br /> .�, . �''" ;�..=r-::;-:",x �tmale,�,.».��,�.'; � � �,�a.„.���-.tls�aa.Pactfi'c•::::-�AP�*..�,.. atucr:: r.:: :: ;; .�"HI <br /> , ;,� <br /> .L- ,.r-. '-' "x:.^w'•,•`%r ,• ,�,y::� ysw q..y;,�;a.Efi ..�„r; Irh- .-y, ,., ':^xM1,s+�'..Yc":'` .-•":: <br /> - `Publicly held �:`.•; �' �� 1�tativtAmericaa. .-NA•` <br /> 8. Is your company registered on the BIDS system? YF_j NQ. <br /> Signature Title Date <br /> visit these web sites for information on BIDS:www.¢ssa.state.co.us;DBE Certification:www dora.state.coms/Certification <br />