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REQUEST FOR A SOLE SOURCE
PROCUREMENT
NOTE: This form is to be used for items that are available from only one source and there are no alternates. Forward to
the Procurement Department sixty (60) days prior to actual need.
Date Submitted:
Requesting Department:
Requestor Name:
Title:
Phone Number:
Email Address:
Commodity/Service Requested:
Describe Performance or Design:
Estimated Price:
Intended Source: (Vendor)
Contact name:
Vendor Address:
Vendor Contact Phone number:
Vendor Contract e-mail address:
Requesting Department Contact Initial below:
This purchase is clearly and legitimately limited to a Sole Source because the commodity or service is:
Item(s) are available from only one source and there are no alternates: ___________
Initials
Attach vendor documentation certifying that the vendor is the only source for the commodities or services in
question or holds the production, copyrights, trademark, and/or patent to the item.
Check the following statement(s) that apply:
The vendor holds the exclusive distribution rights for the item in question. Vendor documentation attached.
The item to be purchased is the only item compatible with existing equipment owned by the College (Single
Source).Vendor documentation attached.
The vendor is the sole provider of the goods or services which have unique characteristics essential to the
needs of the program to perform the intended function and no other goods or services will be suitable for
use by the College. Vendor documentation attached.
What steps were taken to verify that these features are not available elsewhere?
Other brands/manufacturers were examined (please list names, phone numbers, and explain why they are
not suitable for use by the College. Attach additional pages as necessary):
Other vendors were contacted (please list names, phone numbers and explain why those contacted would
not meet the needs of the College. Attach additional pages as necessary):
Clear Form
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State why this is the only source for the required commodity or service (attach additional pages as
necessary):
I certify that to the best of my knowledge, this request is a sole source and the information provided herein is
accurate and truthful.
______________________________________________ Date _________________________
Requester’s Signature
______________________________________________ Date _________________________
Direct Supervisor’s Signature
For Procurement Use Only
Date Received in Procurement: _______________________ Procurement Tracking Number: _____________________
Procurement Staff Reviewer: _________________________________________________________________________
Verified that this request is the only source: Yes No
Posted on Procurement Web-site? Yes No
Date Posted on Procurement Web-site? ________________
Comments:
Procurement Staff Review Signature:
Date: Approved as a Sole Source Denied, Located Alternate Source
Managing Director, Procurement Signature:
Date:
Note: Section 838.22 Florida Statutes, it is unlawful (second degree felony) for a public servant with corrupt intent to
obtain a benefit for any person (company) or to cause unlawful harm to another, to circumvent a competitive bidding
process required by law or rule by using a sole-source contract for commodities or services.
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