*Company Name:


*Main business address:


*Main business phone number:

Main business fax number:

*Business location(s):


Company Web site address: (fully qualified URL: (i.e., http://))

*Contact person:


*Contact phone number:

*Contact email address:

*Discount details:


*Industry:


Licensing, certification, or other requirements (please list all information):

*Secretary of State or Dept. of Revenue business identification number:

*Services or products offered:

*Discount offered to all state employees: Yes No
    If no, list all requested limitations or restrictions on the discount offer:


If your company has a Web site, are you able to create a “splash” or “intro” page, exclusively for state employees, listing the discount details?
If so, please include the entire, fully qualified URL: (i.e, http://)


If no Web site, please email the one-page document you would like posted to vendor.discounts@state.co.us


By sending this application, the vendor is agreeing to all conditions and policies and attesting that all information provided on this form is factual.