
Contractor Application
Pursuant to Statute
§ 39-26.708(1),(2),&(3)
Send completed forms to: Colorado Department of Revenue, Denver, CO 80261 - 0009
Failure to accurately complete all boxes will cause the application to be denied.
89-
Period (MM/YY-MM/YY)
_
Contractor Information
Trade name/DBA
Owner, partner or corporate last name First Name Middle Initial
City State Zip
E-Mail Address FEIN Bid amount for your contract
$
Fax number
( )
( )
Exemption Information
must
98
City State Zip
First Name Middle Initial
City State Zip
( )
(MM/DD/YY) Estimated completion date (MM/DD/YY)
Date (MM/DD/YY)
(Do not write below this line)
*130172==19999*
owned and used
provided by law.
Subcontractors will not
(See reverse side.)
Departmental Use Only
DR 0172 (08/30/13)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261 - 0009
(303) 238-SERV (7378)