Sole Source Request Form (Page 2 of 3) in pdf

Sole Source Request Form Page 2

Sole Source Request Form

Date: ___________________________

From: __________________________

________________________

PI Signature (or designee)

MMRF Account #:__________

Estimated Price: ____________________________________

Proposed Vendor: ___________________________________

Product Description: __________________________________

STATEMENT:

I am aware that MMRF purchasing regulations require that we procure all

materials, equipment, and supplies via competitive means when a purchase

exceeds $3,000. However, I am requesting sole source procurement based on

the following criteria (choose from options I-IV as applicable below, attach

additional sheets as necessary):

___ I. Compatibility

The requested product is an integral repair part or accessory compatible

with existing equipment.

A. Existing equipment: ___________________________________

Manufacturer/Model Number: ___________________________

Age/Current Value: ___________________________________

B. Requested Equipment/Accessory/Part: ____________________

Manufacturer/Model Number: ___________________________

Explain relationship between current equipment and requested equipment:

_____________________________________________________

Version Date: December 24, 2015

Sole Source Request Form Page 2