Fillable F4 Sole Source Request (Mott Community College)

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F4 Sole Source Request (Mott Community College)

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SOLE SOURCE REQUEST FORM | F4
Issue Date: 03/24/2010 Revision: 01/13/2017 (6)
Purchasing Department Page 1 of 2
If the intended purchase cannot be competitively solicited, please complete this form in its entirety and send the completed, signed form to
the appropriate Purchasing Department staff member.
Requisition No.: ______________________________ Requestor: ___________________________________________
Date: ______________________________ Vendor Name: ___________________________________________
Vendor Contact: _____________________________________________________________________________________________
Vendor eMail: _____________________________________________________________________________________________
Vendor Phone: ______________________________ Estimated Value: __________________________________________
TYPE OF REQUEST:
Select one:
Sole Source: Item or service is available from only one vendor (i.e. an item or service which is one-of-a-kind
or is not sold or provided by another vendor).
Sole Brand: While multiple vendors can supply the specified model & brand, no substitutions for the
specified brand are to be considered (i.e. brand specific).
WHAT IS THE INTENT OF THE PURCHASE?
Give a brief explanation of why the purchase is needed and who it is being purchased for (i.e. who will use it).
WHAT IS BEING PURCHASED?
Give a brief, non-technical description of the proposed item or service. Include the make, model and specific features
or functions this item performs or the unique nature of the service and how it is delivered. Attach additional sheet(s) if
necessary.
Specifically identify the unique features, qualifications or requirements the proposed item or service has that are not
available in any other item or service. Indicate why these unique features are required.
Will this purchase obligate MCC to future purchases (maintenance, licensing, etc.)? Yes No
WHY WAS THIS VENDOR CHOSEN?
Item or service is proprietary to the vendor (trademark, patent, copyright, license, trade secret, etc.)
Unique features, qualifications, or requirements which are not available in any other item or brand
(features/qualifications/requirements must be defined above when this option is selected)
SOLE SOURCE REQUEST FORM | F4
Issue Date: 03/24/2010 Revision: 01/13/2017 (6)
Purchasing Department Page 2 of 2
WHY WAS THIS VENDOR CHOSEN? Continued
Substantial technical risk in contracting with any other contractor
Other options are cost prohibitive (provide additional explanation)
Item is needed…
…to be compatible with _________________________________________________________________
…as a spare, replacement, repair or modification of existing hardware for
______________________________________________________________________________________
…for technical evaluation or testing
Other (provide additional explanation)
WERE OTHER SOURCES OR BRANDS EVALUATED? Yes No
Provide information on other vendors that were contacted; include brand name, make, model, and vendor name. For each
vendor, explain why they cannot provide the requested item or service. If no other vendors were considered, explain why.
I am aware of MCC’s Purchasing Policy and established criteria for competitive purchasing. I have gathered the required technical
information and have made a concerted effort to review comparable/equal equipment or services. This effort is documented in this request
form. I hereby certify as to the validity and accuracy of this information and am confident this request for sole source/sole brand
procurement meets the criteria provided by MCC.
_________________________________________________________________ ____________________________
Requestor Date
_________________________________________________________________ ____________________________
Cost Center Manager Date
Please attach a copy of the quotation from the sole source provider, along with any other documentation or
research that has been completed for this request.
For Purchasing Use Only
Compatibility or standardization? Yes No Valid until: ______________________
Is the requested vendor the manufacturer? Yes No
Does the manufacturer sell through distributors? Yes No
Is the requested vendor a service provider? Yes No
Purchasing Approval Yes No Initials: _________________________
PO or BPO Number Issued: ________________________
_________________________________________________________________________ _______________________________
Purchasing Manager Date
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F4 Sole Source Request (Mott Community College)

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Completed 21 July 2020

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