UW Procurement Services
Sole Source/Justification Request
Sole Source Considerations - (check all applicable categories and provide detailed justification below)
*Repair/replacement part or accessory: For existing equipment and is available from only one source.
Existing Equipment: Manufacturer/Model number:
*Sole source distribution: The item is manufactured and sold exclusively by vendor or vendor holds exclusive rights for
distribution.
*Exclusive design: Item possesses a unique function or capability critical in the use of the item and is not available from any
other sources.
*Services: Services are available from only one source.
* Detailed Justification: Explain what unique qualifications or features are required, how selected contractor or vendor
exclusively meets those qualifications or features, and why the service or goods cannot be obtained through the bidding
process. (use next page or attach additional sheets if necessary).
For goods and services valued $10,000 - $99,999.99, I hereby
declare the information provided herein to be
true and accurate to the best of my knowledge.
Requester Name (print) Signature/Date
For goods and services valued $100,000 or more, the below signatures are required.
College Dean or
Department Head (print)
Associate Vice
President (print)
Signature/Date Signature/Date
Procurement Approval/Date
Requester Name:_______________________________ Department:________________________________
Name of Manufacturer:_____________________
Name of sole source provider:________________
Sales Contact:____________________________
Price Quotation: Attach a firm price quotation from the vendor for the item/services identified above.
Quoted prices shall be firm for 30 days and all associated costs including shipping. Quote must have the
freight terms D.A.P. Incoterms
®
2010, University of Wyoming, Laramie, WY, 82071
Charge Account (Please format as Entity-Account-Fund Class-Fund Source-Organization-Exp Class-Program-Activity-Future):
________________________________________________________________________________________________________
____________________________________________________________________________________________________
Procurement Office (Signature required before attaching to requisition for the purchase of any goods or services).
Revised July 2019
