SOLE SOURCE REQUEST
Sole Source Procurement is appropriate only if a purchase requirement is reasonably available from a
single supplier, or if it otherwise qualifies under the attached sole source definition.
ALL SOLE SOURCE REQUESTS OVER $5,000 MUST BE PRE-APPROVED BY THE
PURCHASING DEPARTMENT.
It is anticipated the procurement will result in a (check one):
___ Contract: E-mail this form to the Purchasing Department prior to contract negotiations; no
requisition is required. Requested contract term (include requested renewal options, if any):
___ Purchase Order: Enter requisition into Banner, insert the requisition number here___________,
send this form to the Purchasing Office, along with a copy of the vendor’s quotation.
_____________________________________________________________________________________
Department Requesting Approval: ________________________________________________
Division or Office, if applicable: __________________________________________________
Contact Person and Title: ________________________________________________________
E-mail Address: ________________________________________________________________
Phone Number: ________________________________________________________________
______________________________________________________________________________
Product(s) or Service to be purchased:
Approximate Cost: $__________________
_____________________________________________________________________________
Recommended Supplier:
Contact Person:
E-mail Address:
Phone Number:
City, State, Zip:
Type of Supplier (check one): ___ Corporation ___ Government
___ Partnership ___ Sole Proprietorship
___ Other
______________________________________________________________________________
Sole source justification is based on which of the following (check all that apply):
___ Compatibility of equipment/service (please complete sections A and B below)
___ Equipment/service is only available from a single supplier in the U.S. (please complete section A)
___ Compatibility of professional services (please complete section A)
Section A. GENERAL INFORMATION
1. What is unique about this product or service to justify a sole source purchase?
2. Could the product/service be reasonably modified to allow for competition?
3. Explain the market research performed to make the sole source recommendation. This
must include price comparisons to other products/services similar, but not equal to, the
product in question.
4. List the names of suppliers contacted, contact person and a summary of their responses.
5. If the requestor has any personal, financial or fiduciary relationship with the
recommended supplier you must attach a complete disclosure statement to this form.
Please complete the Declaration of Business Interest form located on the Purchasing
Office website. Does such a relationship exist? ___ Yes ___ No (check one)
Section B. COMPATIBILITY OF EQUIPMENT/SERVICE
1. Describe the existing equipment in which this purchase must be compatible. Also
include the purchase price of the existing equipment and date of purchase.
2. What is the remaining life expectancy of the existing equipment?
3. What procurement method was used to purchase the existing equipment? Please provide
the requisition number, bid number or purchase order number.
Section C. TRIAL OR TESTING
Please read U.C.A. 63G-6a-802.3 regarding purchasing products for trial or testing prior to
completing this section.
1. Why is the trial use or testing necessary?
2. What is the anticipated end result of the trial or test?
3. Do any other suppliers provide a similar product or service?
a. If yes, list the company names:
b. Will their products be tested? If not, why will they not be tested?
______________________________________________________________________________
Department Purchasing Department Vice President
____________________ _________________________ ____________________
Signature Signature Signature
____________________ _________________________ ____________________
Print Name Print Name Print Name
____________________ _________________________ ____________________
Date Date Date
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Conditions For Use of Sole Source Procurement
Sole source procurement shall be used only if a requirement is reasonably available
from a single supplier. A requirement for a particular proprietary item does not
justify a sole source procurement if there is more than one potential bidder or offeror
for that item.
Examples of circumstances which could necessitate sole source procurement are:
(1) where the compatibility of equipment, accessories, replacement parts, or
service is the paramount consideration;
(2) where a sole supplier's item is needed for trial use or testing;
(3) procurement of items for resale;
(4) procurement of public utility services.
The determination as to whether a procurement shall be made as a sole source shall
be made by the Chief Procurement Officer of the University. Each entirely
completed request shall be submitted in writing by the requesting Department. In
cases of reasonable doubt, competition will be solicited.