Procurement and Contract Services
P.O. Box 425439 / Bralley Annex
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Denton, TX 76204-5439
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P
:
(940) 898-3812
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F
:
(940) 898-3519 Rev: 10/16
Sole Source Justification/Approval Form REQ #_________
PO # __________
Complete this form when only one source is available for goods or services requested or when only one product will meet your needs.
Respond to all questions that apply. The state requires that we obtain three bids when possible. Please complete and forward to the
Purchasing Department. If more space is needed, please attach additional page(s).
PURCHASE INFORMATION
1. Provide Estimated Price.
2. Provide name, manufacturer, and model number of item being purchased or the services to be purchased.
3. Provide Description of requested items or services and their purpose(s). Add additional sheet if needed.
4. Reason(s) for requesting a sole source purchase:
□ Original manufacturer or provider; no other local distributors exist.
□ Only local distributor for the original manufacturer or provider.
□ Only known item or service matching the requested needs or performing the intended task.
□ Sole provider of a licensed or patented good or service.
□ Sole provider of items compatible with existing equipment, inventory, systems, programs or services.
□ Sole provider or factory-authorized warranty service.
□ None of the above applies (Please attach a detailed explanation and justification for this sole source request.)
5. Explain why the product or service requested is the only one that can satisfy your requirements.
6. Identify other sources reviewed and why they are unacceptable. Be specific with regard to specifications.
Attach additional pages if necessary.
I certify that the above statements are true and correct, and that no other material fact or consideration offered or given has influenced
this recommendation for a sole-source or proprietary purchase.
Print/Type Name Print/Type Title Department
Account Approver Signature Date T
elephone Number
PURCHASING USE ONLY
Reviewed by: Date:
Approved by: Date:
AVP for Procurement and Contract Services (or designee)
