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olorado O c Cpz� <br /> rocurement �� _ ��?� <br /> egistry STATE OF COJ.�ORADO <br /> Procurement Registry <br /> iT2k.- for Colorado Business K Cuk 15upPR'a ft Col UP04flot�4CW111r^n 1876 <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.htin) <br /> 7. Ownership information (use additional-pages if necessary): <br /> I:ASTNAtri =" ` �" a�_s L-E °aOwNED' "t;G]EidDE 'ETMUCiTya <br /> '•Y•« �:'fa'� rvl. K *t <br /> A1I7TL�ti;6 ;(SFE B W,� •. �� <br /> ;^^ "" Geader'/Type'codesx* ale.:�°"'" :°:::.: M• Etfioicity codes ** ``' i.•» r <br /> .Y,rro*t.. '•. +�y;,sr��� ?"„•. .r. a a"4i'z'�-«v,` «. ..�;p� <br /> CiI18It- wzJ+ w` � v.:Z ..,.„ •a w v. - �I pacifl <br /> 4 ro <br /> .t :+ ,�p`��S" `8+',„�.>i •t„ y.,.,. a a�R.:-•�'w,,';`:�s �I.v.w,.+j'+:�•- Whife on-Hispanic}.,.Ww <br /> ••r-, µ.me: 'R^r . r. ;,;z":t•y ':.i: , .a1`•.. .-x*. ..�,.,*� = +*--:� •:'•s»ata':- <br /> 'Publiclyhtld P? :•,x1rla2iveAm�ricaa. ,.NA• ;..•CJther .OF'' <br /> 8. Is your company registered on the BIDS system? YF� NQ. <br /> Signature Title Date <br /> visit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />