UTS PROCUREMENT POLICY EXEMPTION APPROVAL FOR UNDERTAKING A SELECT TENDER [Insert project name] TRIM REF: [insert TRIM reference] [insert estimated value] DATE: [insert date] REQUESTED BY: [insert name] PHONE: [insert phone number] FACULTY/BUSINESS UNIT [insert faculty/business unit name] PROJECT NAME: ESTIMATED VALUE ( EXCL GST): (ANNUAL FOR PERIOD CONTRACT) Request this type of exemption when: There is special reason to invite only a select number of suppliers to tender, rather than making the opportunity publicly available to all interested and capable suppliers as is required by the “FULL TENDER GUIDE ($250K +)”. 1 Describe the acquisition [Insert a full description of the acquisition, including the estimated value] 2 Incumbent details [Enter the supplier/s name used currently, UTS’s total annual expenditure and the number of years providing goods or services.] 3 Have these goods/services been tenders previously. If so provide details. [Provide information about any previous tenders, dates, tendering frequency, tender process steps, stake holder involved.] 4 Describe market research undertaken [Describe any market research undertaken to identify all suppliers of these goods/services] 5 List the names of the suppliers you wish to limit the tender invitation [Provide a list of suppliers you intend to invite. Include clear reference to any potentially capable suppliers who will consequently be excluded from invitation] 6 Detail the reasons for your exemption request (please attach supporting documents if applicable) [provide the list of proposed suppliers and detail the reasons why no other capable and interested suppliers should be given an opportunity to bid for this business] 7 Which of the following best describes your reasons for undertaking a Select Tender ☐ Where, for reasons of extreme urgency bought about by events unforeseen, the goods, works, or services could not be obtained in time under an open/public tender. ☐ In oglipoly situations where the market is dominated by only a small number of suppliers and you wish to invite them all directly without publicly advertising the opportunity. ☐ Other (please state): [Describe your other reason here] Important Note to Approvers: Approvers should exercise extra caution when approving ‘Other’ as a reason 8 Do all members of the project team unanimously agree that this tender should be restricted to the suppliers listed in point 5 above, rather than undertaking an Open tender process? [list team member names and confirm their acceptance] 9 Requester Declaration I declare that the information that I have provided in this form is complete, true, and accurate in every detail: ________________________________________Signature [Insert name and title of Requester] Document Type: Mandatory POLICY EXEMPTION APPROVAL – SELECT TENDER Project Name/Ref: Click here to enter text. 10 Date: Click here to enter text. Exemption Approval for Values in excess of $250,000 (ex GST) In approving this exemption I understand my obligations under the UTS Code of Conduct in relation to any Conflict of Interest, and hereby declare I do not have any professional, personal or family allegiance, bias, inclination, obligation or loyalty which may affect my objectivity, independence or impartiality in approving this request. Further, I do not have any personal financial interest in the goods/services being provided, nor to the best of my knowledge do any of my relatives or friends. Comments: Date: Name: Director, Dean or Similar Comments: Date: Mark Leigh CFO Comments: Date: Patrick Woods Deputy Vice-Chancellor (Resources) After this form has been signed, please immediately send it to the Strategic Procurement office so that it can be listed on the ‘Procurement Policy Exemption Register’. The form can be posted via UTS’ internal mail system, or delivered personally to: Strategic Procurement Office, Building 10, Level 6, 235 Jones Street, Broadway NSW 2007 Alternatively the form can be scanned and emailed to: firstname.lastname@example.org DECLARATION OF INTEREST (V1) POLICY EXEMPTION – APPROVAL TO UNDERTAKE A SELECT TENDER I, of Please insert your full name Please insert your position title and dept/divsn name In relation to the proposed purchase described in this exemption request, 1. declare that I agree to: i. ii. iii. iv. 2. use my best judgement and be accountable for the achievement of objectives related to this purchase demonstrate personal integrity and ethical behaviour; neither accept nor seek to gain any unfair advantage, gift, gratuity or hospitality for myself, or my relative(s) report to UTS Internal Audit if I witness any behaviour that conflicts with any UTS Policy or Procedure to the best of my knowledge have no conflict of interest in relation to the subject being discussed other than: Source of income Do you have a source of income or reward from any commercial party that could potentially benefit either directly or indirectly from this purchase? Office holder Are you an office holder in any company, trustee company or other body in which you hold office (whether it is a public or private company) that is related directly or indirectly to this supplier? Trusts, Shareholdings and other business interests Do you have any trusts, shareholdings, investments or other business interests in any entity related to this supplier? Agreements Do you have any contract, agreement or understanding entered into by you or a member of your immediate family that gives rise to an obligation or an expectation of reward, such as an agreement about future employment in relation to this purchase? Other interests: Any other substantial financial or other interest held or accruing to you or a member of your immediate family which you are aware which could reasonably raise an expectation of a conflict of interest with your involvement in this purchase? If Yes, please give details no yes no yes no yes no yes no yes This information is true and correct to the best of my knowledge. I declare that as far as I am aware none of these private interests conflict with participation in this purchase. I undertake to advise UTS Internal Audit if a conflict or potential conflict arises during any stage of the process, and to withdraw my involvement at that time if so required. Signature of Person making Declaration Signature and Name of Witness Date of Signature Date of Signature Why is a declaration made? The completion of this declaration is a safeguard for you and UTS. The purpose is to avoid any conflict of interest between your private interests and your work duties. The Code of Conduct provides guidance on how to avoid a conflict of interest. This includes: standing down in any part of the process in which you may be compromised not using your position to obtain a private benefit for yourself or someone else not allowing your decisions to be improperly influenced by family or other personal relationships not seeking or accepting gifts or favors for services performed in connection with your work not selling or buying shares in a client company at a time when you possess information that could, if publicly disclosed, affect the value of such shares not engaging in outside employment or in the conduct of a business, trade or profession without written authority of UTS Who sees the declaration? Only those persons duly authorised by the Vice Chancellor having a bona fide reason may have access to this document. The declaration will be kept on a confidential TRIM file at UTS. How to complete the form Answer all questions, noting those which are not applicable to you. You may attach additional pages if there is insufficient space on this form for all the information required. Make reference to additional pages on this page. Each additional page must be dated and signed by you.