BELOIT COLLEGE PROCUREMENT SOLE SOURCE JUSTIFICATION AND APPROVAL FORM
1. Estimated contract amount: $
2. Recommended supplier name, address, and contact information:
3. Description of requested items or services and its purpose(s):
4. Reason(s) for requesting a sole source purchase (Please check all that apply):
Original manufacturer or provider; no other local distributors exist.
Only local distributor for the original manufacturer or provider.
Parts or equipment not interchangeable with similar parts of another manufacturer.
Only known item or service matching the requested needs or performing the intended task.
Sole provider of a licensed or patented good or service.
Sole provider of items compatible with existing equipment, inventory, systems, programs or services.
Sole provider of goods or services established as standard (Please provide evidence of such a standard).
Sole provider of factory-authorized warranty service.
Used item representing good value and advantage.
None of the above applies (Please attach a detailed explanation and justification for this sole source request).
5. Explain why the product or service requested is the only one that can satisfy your requirements, as well as why
alternatives are unacceptable. Be specific with regard to specifications. Attach additional pages if necessary.
6. Does this purchase obligate the College to a particular vendor for future purchases, i.e. maintenance or service? If
yes, please provide details.
7. What are the consequences to the College, including an estimate of the impact (financial or otherwise), if this sole
source is not authorized.
EQUESTED
Y
EPARTMENT
PREPARED BY : DATE :
I hereby certify that, to the best of my knowledge, the above justification is accurate and request that a sole source be approved
for the procurement of the above requested items or services.
SIGNATURE:
R E S E R V E D F O R VICE PRESIDENT FOR FINANCE AND PLANNING O N L Y
SIGNATURE:
__________________________________________
NAME:
APPROVED
NOT APPROVED
– Reason for denial:
NAME:
