Fillable NSU SINGLE/SOLE SOURCE JUSTIFICATION FORM

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NSU SINGLE/SOLE SOURCE JUSTIFICATION FORM

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The NSU SINGLE/SOLE SOURCE JUSTIFICATION FORM form is 1 page long and contains:

  • 2 signatures
  • 9 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Nova Southeastern University

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SINGLE/SOLE SOURCE JUSTIFICATION FORM
Updated 02.222017 Contact us at 954-262-8841 or by email at purchasing@nova.edu for additional information.
Complete this form when requesting an exception to the university’s competitive bid policy where only one firm has a product that will meet the project’s
needs or product specifications, or only one firm can do the work requested. Completing this form does not guarantee that the proposed vendor will be
selected. It is the requester’s responsibility to provide all required information and documentation as indicated in this form. Approval and verification
signatures maybe captured through the use of Adobe electronic signature or by printing and signing this document.
The Office of Procurement Management reserves the right to competitively bid, negotiate, or solicit additional information and remains the final
authority on all procurement issues.
Definitions
Sole Source: The ONLY known supplier for unique products and services where no other options are available
Single Source: Though there may be alternate sources for the product or service requested, circumstances dictate the use of the proposed vendor. I.e.,
availability, timeliness, location, etc.
Part I: General Requester Information
Department Name:
Purchase Requisition # (if applicable):
PI/Requester Name:
Check Request # (If applicable):
PI/Requester Phone:
Funding to be used: University Funds Sponsored Program Other (Explain)
PI/Requester Email:
Total Amount of Purchase:
Part II: Vendor Information
Vendor Name:
Vendor Contact Name:
Vendor Contact Phone:
Vendor Contact Email:
Part III: Sole/Single Source Justification (check one or more)
DESCRIPTION OF PURPOSE: The Manufacturer, model number and / or generic description.
Scientific reasons and /or research and analysis has determined that the good(s) or service(s) requested are available from only one vendor or manufacturer
and is the only product that will meet requester’s needs. Describe the unique characteristics of the product or service in the space provided below.
Supplier or Item specifically required by sponsored award or contract provisions. Provide a copy of the award or contract referencing this requirement.
Utility, fixed rent or government/state/municipal/agency mandated services. Provide a copy of the mandate.
Emergency repair services or parts replacement. Emergencies are defined as an immediate need for goods or services whereby the failure to act expeditiously
exposes the university to risk of harm to people or university property, or when failure to act jeopardizes the learning environment.
Compatibility with existing university systems or equipment is required. Provide documentation of existing system or equipment.
Other, please explain in the space provided below.
Part IV: Confirmation of Documentation
Have you provided required documentation for this request in support of the justification in Parts III of this form?
You may also attach any additional information not specifically requested on this form to support your single/sole source
justification.
Part V: Requesting Department Approvals
PI/Requester Name
PI/Requester Signature
Date of Signature
Director, Dean, or VP Name
Director, Dean, or VP Signature
Date of Signature
This single / sole source form may be used during the time period noted; as it pertains to a special project or a sponsored program.
_______________________ ________________________
Start Date End Date
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NSU SINGLESOLE SOURCE JUSTIFICATION FORM

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Completed 18 January 2020

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