For office use only
Vendor Name
Sole Source #
PROCUREMENT SERVICES
SOLE SOURCE JUSTIFICATION FORM
Requests missing information will not be processed and will be returned to the requestor for completion.
ALL SOLE SOURCE JUSTIFICATION FORMS MUST BE APPROVED BY PROCUREMENT SERVICES.
Sole source procurement shall be used only if a requirement is only reasonably available from a single supplier. A
requirement for a particular proprietary item does not justify sole source procurement if there is more than one
potential bidder or offeror for that item.
The determination as to whether a procurement shall be completed as a sole source shall be made by Procurement
Services. Procurement Services will specify the application of the determination and its duration. In cases of reasonable
doubt, competition will be solicited.
Please fill out the following form, have it signed by your department head, and send it to Procurement Services (MS
188). Procurement Services will review it and determine if the requirements for sole source procurement are met. If
Procurement Services determines the requirements for sole source procurement are met, the justification form will be
sent to the appropriate vice president for approval.
Department Information
Department Name:
Contact Person and Title:
E-mail Address:
Telephone Number:
Requisition Number:
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Vendor Information
Vendor Name:
Contact Person:
Phone Number:
Address:
City, State, Zip:
E-mail Address:
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Approximate Cost:
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Describe, in layman’s terms, the product or service to be purchased and the purpose it will serve.
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Sole Source Justification Form
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1. Does this product or service need to be compatible with existing equipment? ☐Yes ☐ No
IF YES:
a. List the equipment with which it must be compatible, the date it was purchased, the life expectancy, name of
the vendor from which it was purchased, and the purchase order, bid, or requisition number.
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b. Why must the two products be compatible?
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IF NO:
a. What is unique about the product or service? List specific features, specifications, or attributes of the requested
product or service which are not found in competitors’ product or service.
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b. Explain why we need the unique features of this product or service.
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c. Describe the research used to make this determination. List the products or services that were reviewed and
the approximate costs of those products or services.
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2. Could this product or service be modified to allow for competition?
☐Yes ☐ No
IF YES:
a. Write the bid specifications below.
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IF NO:
a. Explain why it cannot be modified.
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I certify that the statements I made in completing this document are true:
_________________________________________________
Signature of Preparer
Date
I agree with the statements made in this document:
_________________________________________________
Signature of Department Head
Date
Sole Source Justification Form
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I agree
I disagree with this Sole Source request:
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Signature of Procurement Services Buyer
Date
Buyer’s Comments:
Approved by Procurement Services Director or Associate Director:
_________________________________________________
Signature
Date
Approved by Vice President:
_________________________________________________
Signature
Date
Sole Source Justification Form
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