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olorad0 O�•COlO <br /> rocurement STATE OF COLORADO ��� 90, <br /> egistry �„ 01 <br /> Procurement Registry <br /> rft\ for Cofarado Business 187r, <br /> c.,.,.iwppmw.xe+ cow.,�na�,Jccn�Ormn <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 <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 /> GEriDirxl tytrE:. ErxmcM <br /> ENAII'M FfftSrNAME MtuDr.E °la OWNEDII4rrL L <br /> codes * ,Male. �.:.»:...M. . -Etbgicity codes c..............::.,.M8. •_�: �g• «�Asian�l'Rcifia 'AP ; � ., ;� °. <br /> ed 'Tnlie:... ,T Black`; ....:.::..::aBL`, White(non-Hispanic). . <br /> VM <br /> '` �y :' `{ :OT <br /> ::.. <br /> Pubiicly held".::..:.::.P 'Native American.::NA"-`` <br /> er <br /> 8. Is your company registered on the BIDS system? Y❑ NQ <br /> Signature <br /> Title Date <br /> vicit these web sites for information on BIDS:www.essa.state.co.us;DBE Certification:www.dora.state.co.us/Certification <br />