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olorado ��'Cn� <br /> istr ment e , O t'�AD O <br /> ' gistry STATE OF CO� <br /> > o <br /> Procurement Registry *I <br /> for Colorado Easiness \ 1 g 7 6 <br /> CrK ISuppR.`avltn CUAnH1n l�Ifla,M Ctnitkmnn \� <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 /> x �w' IltS DAMEON <br /> % = IIIE a y� GEttm , En�ncrnt _ <br /> F:"� <: =:tom a "�:7•�Lesz°, AME. S"dsF� <br /> rTiAi .(SE. HEI <br /> � `Gender/Type'cgdes * al"e'� <M7 Ethoicityeo'des`*� �• c � t ;: <br /> - ,�..t r��v�M 1'y`y-.„..�:".."`.:. ..sya, a.a+', •'i1C^ 'ti' 7'z`Yu*ve;.. ..> Y, .•x. ,R'. ».. <br /> ^� � <br /> ,Owned fe <br /> � <br /> by.Tnbe:°: :FT. Y�� °' .Black: �m _,e � : Whi non-Hispania:�^�; <br /> 'tlmerican '.NA <br /> ative <br /> "r . .. Publicly held. P" •_ <br /> 8. Is your company registered on the BIDS system? Yr_� NQ. <br /> Signature Title Date <br /> visit these web sites for information on BIDS:www.sssa.state co.us;DBE Certification:www.dora.state co.us/Certification <br />