Fillable Louisiana Tech University Purchasing Department Sole Source Justification (Louisiana Tech University)

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Louisiana Tech University Purchasing Department Sole Source Justification (Louisiana Tech University)

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Louisiana Tech University
Purchasing Department
Sole Source Justification Form
Budget Unit Name: Budget Unit No.:
Name of Person Submitting Form:
Title or Rank of Above Person:
Highest Level of Education or Qualification Achieved:
1. State relevance of purchase to your mission, purpose, research or study:
2. Identify items or services to be approved for Sole Source treatment:
3. Name of Manufacturer of item(s):
4. Name of Single Source Supplier:
Contact:
Contact Email:
Mailing Address:
Phone Number:
Fax Number:
Web Site Address (if available)
5. If purchase related to compatibility with existing equipment, then identify the item(s) and applicable tag
numbers(s) of State equipment:
6. SOLE SOURCE CONSIDERATIONS – (Mark the one that best qualifies)
A. Exclusive Rights . . . Item under patent or copyright held by a single vendor and item possesses
functions or capabilities critical to use. (Complete Sections 7 & 8 and attaché patent/copyright info).
B. Exclusive Design . . . . Item possesses a unique function or capability critical in the research or use of the
item and not available from any other sources. (Complete Sections 7 & 8).
C. Enhancements of Existing Equipment . . . The purchase is for accessories sought for enhancement of
existing equipment where compatibility with equipment from original manufacturer is paramount.
(Complete Section 5, 7 & 8).
D. Replacement Equipment . . . The purchase is for equipment associated with use of existing equipment
where compatibility is essential for integrity of results. (Complete Sections 5, 7, & 8).
E. Replacement Parts . . . The purchase is for replacement parts needed for repair of existing equipment
where compatibility with equipment from the original manufacturer is paramount. (Complete Sections 5, 7
& 8)
F. Technical Service . . . The purchase is for technical services associated with the assembly, installation or
servicing of equipment of a highly technical or specialized nature. (Provide detail in Section 8).
G. Continuation or Prior Work. . . Additional item, service or work required, but no
t known to have been
need
ed when the original order was placed with vendor. (Provide detail in Section 8)
H. Other . . . (complete Sections 7 & 8)
State
7. SOLE SOURCE DISTRIBUTION – (Mark one that qualifies)
A. The item is manufactured or produced by entity, or entity holds exclusive rights to item, and entity solely
transacts (sells) direct to the customer. (There are no dealers or distributors for entity)
B. The item is manufactured or produced by entity, or entity holds exclusive rights to item, and entity does
not sell direct to the customer. Entity sole distributes the item through only one dealer or distribute in the
work, United States, region, Louisiana or identified market area.
Note: If item available from more than one source, the item may be treated as proprietary, but must be
competitively solicited from multiple (two or more) sources of supply.
ATTACH CURRENT DATED AND SIGNED LETTER FROM MANUFACTURER PRODUCER OR
RIGHTS HOLDER OR INCLUDE STATEMENT ON FIRM PRICE QUOTATION SUBSTANTIATING
SELECTION “A” OR “B” ABOVE.
8. DETAILED JUSTIFICATION FOR NOT BIDDING – (Precise Explanation Required)
A. Explain the unique functional or performance requirements that must be met for the research or use of the items.
Brand preference, preferred favorite or “only source known” are not qualifying sole source explanations. Please
be brief, but concise.
B. Detail the item’s component parts that must meet requirements outlined above and why, if applicable, competing
products are not equivalent. Please be brief, but concise.
9. FIRM PRICE QUOTATION NEEDED
Attach dated firm price quotation from sole source or sole dealer/distributor pricing the product(s) or service(s)
identified in section 2. Quoted prices shall be firm and inclusive of all costs including transportation.
10. SIGNATURE REQUIRED
I hereby declare the information provided herein to be true and accurate to the best of my knowledge. I
understand any false or misleading information may be considered a violation under the LA Procurement Code
and can subject me to prosecution and penalty under Louisiana Revised Statute 39:1679.
Name: Signature:
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Louisiana Tech University Purchasing Department Sole Source Justification (Louisiana Tech University)

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Completed 22 August 2020

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