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OF Colo\ <br /> olorado <br /> rocurement STATE OF COLORADO " _0 <br /> egistry ' 11 <br /> Procurement Registry <br /> LA for(olorado Business �1876 h4nxn CoMxuln CNNotM CMlfkann <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. Questions about the registry should be <br /> directed to(303) 894-2355. 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 /> FEIN <br /> 1. Legal Name of Business <br /> List dba,if any <br /> 2. Mailing address <br /> City <br /> State Zip+4 <br /> 3. Business phone <br /> Fax <br /> 4. E-mail address <br /> Web address <br /> 5. Name of Contact person: Last <br /> 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 /> MIDDLE o/a QtYNFD; GFNDE[tfi ' 1tII7Iary,' <br /> 1 kSTNAM ." >: ; FIItsTNAME ���* {sue*ssio�v) (s> �• as(ivr} <br /> • Malo, pM. . Ethnicity codes•** . <br /> y:.Geoderlfype codes. qp"". Hispanic.:..........:....... <br /> tea' Female,,:.::�::... F." .Asian Pacific.... },. WH <br /> Black BL: Whttc(n°n'Hispanic <br /> w t)wried by' nbe. .. t)sher. .. <br /> :.. Publicly held.::».:. ,.:P' <br /> Native American...NA:" <br /> 8. Is your company registered on the BIDS system? Y❑ N[]• <br /> Signature <br /> Title Date <br /> Vkit these web sites for information on BIDS:n2ny ossa.state.co.us;DBE Certification:MMdora.state.co.us/Certification <br />