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olorado OF,.COL <br /> rocurement ` � o\� <br /> rocuregis y STATE OF COLORADO NQ o <br /> Procurement Registry <br /> Lffnih_ <br /> for Colorado Business \ 1876 <br /> Cantal Suppn­ COMInAU UIflQM Cmllkamn <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 /> 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 /> F _ E ;r MIDDLE ,%GOWNED "GEt+IDERI I,YPE ETW[C rry <br /> LAST'NAME RMIAL {SEE*BEIAW) (SEE**BELOW) <br /> Gender/Type codes *.,Male <br /> Etlioicity codes. HI <br /> s,..f Aiian'Pacific'. .. AP Hispanic:....:.....:..». 7 <br /> .r'�iar :ev`p"r: ?!• , .• :s.;, j,• i WAiiuG..•.... ....... 1"„ w'3 ). WH <br /> .I gL"- White(lion-Hispanic . <br /> 0r vjed by Tnbc:: .:. Black" ........... <br /> �. Publicly held ; Other.................:....:OT <br /> . - >. . P" Native American.. .NA <br /> 8. Is your company registered on the BIDS system? Yf__j N0. <br /> Signature <br /> Title Date <br /> Vkit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />