Interrogation Booth Upgrade_Sole Source1.pdf

SOLE SOURCE / NAME BRAND JUSTIFICATION FORM

Section/Unit Name: ______________________________________________________

Requestor: ____________________________ Ext: ___________________________

1. State Relevance Of Purchase To Your Mission, Purpose, Research or Study:

2. Identify Items Or Services To Be Approved For Sole Source/Name Brand Treatment:

3. Identify Sole Source/Name Brand Manufacturer:

Name of Mfr __________________________________________________________

Mailing Address _______________________________________________________

Phone Number ________________________________________________________

Fax Number __________________________________________________________

Web Site Address (if available) ___________________________________________

4. Identify Provider/distributor of Service/Supply (if different from item 3):

Name _______________________________________

Address _____________________________________

Phone Number ________________________________

Fax Number __________________________________

5. If the Purchase is Related To Compatibility With Existing Equipment or Service, Then Identify the Item(s) or Services(s):

6. What specific efforts have been made to determine the availability of another source?

7. SOLE SOURCE CONSIDERATIONS - (Mark Only The One That Best Qualifies)

A. [ ] Exclusive Rights - Item under patent or copyright held by a single vendor and item possesses functions or capabilities critical to use. (Attach applicable support & provide detail in Section 11) B. [ ] Proprietary Design - Item possesses a unique function or capability critical in the use of the item and not available from any other sources. (Provide detail in Section 11) C. [ ] Replacement Equipment - The purchase is for equipment associated with use of existing equipment where compatibility is essential for integrity of results. (Complete Section 5, 8 & 11) D. [ ] Replacement Parts - The purchase is for replacement parts needed for repair of existing equipment where compatibility with equipment from the original manufacturer is paramount.

(Complete Section 5, 8 & 11)

E. [ ] Replacement Accessories - The purchase is for accessories sought for enhancement of existing equipment where compatibility with equipment from the original manufacturer is paramount. (Complete Section 5, 8 & 11)

F. [ ] Technical Service - The purchase is for technical services associated with the assembly, installation or servicing of equipment of a highly technical or specialized nature. (Provide detail in Section 11)

G. [ ] Continuation Or Prior Work - Additional item, service or work required, but not known to be have been needed when the original order was placed with vendor. (Provide detail in Section 11)

H. [ ] Emergency Situation - Purchase must be made immediately. An explanation of the urgency, including a description of why the item or service is critical; and why only the proposed vendor can meet it. (Lack of advance planning is unacceptable.) (complete Section 9)

I. [ ] Exclusive Capability - Only one vendor qualified. No other potential vendors known.

(Complete Section 10 & 11)

J. [ ] Other - (Provide detail in Section 11)

8. REPLACEMENT EQUIPMENT, PARTS OR ACCESSORIES - (Mark One That Qualifies)

A. [ ] The item is manufactured or produced by the supplier and the supplier solely distributes (sells) direct to the customer.

B. [ ] The item is produced by the manufacturer, but not sold direct to the customer by the manufacturer, and the manufacturer solely distributes the item through a single supplier in the world, United States, region, Arizona or identified market area.

Note: If item available from more than one supplier, the item can be treated as proprietary, but must be competitively solicited from multiple sources of supply.

ATTACH SIGNED LETTER FROM MANUFACTURER OR STATEMENT ON PRICE

QUOTATION IF MANUFACTURER IS SUBSTANTIATING SELECTION FOR "A" OR

"B" ABOVE.

9. EMERGENCY REQUIREMENTS - (Complete A - C) [NOTE: Failure to Plan is Unacceptable]

A. Explanation of the urgency:

B. Description of why the item or service is critical:

C. Why only the proposed Manufacturer/Supplier can meet need:

10. EXCLUSIVE CAPABILITY - (Mark The One That Best Qualifies)

A. [ ] Requires specially trained personnel to accomplish task.

B. [ ] Possesses widely known specialized expertise to accomplish task.

C. [ ] Possesses unique test equipment or facilities for need or task.

D. [ ] Responsible for integrated system performance where warranties or results will be voided if other products or vendors are introduced.

E. [ ] Quality of equipment from other known vendor sources have been demonstrated to be inferior or documented to be unacceptable.

ATTACH DOCUMENTATION TO SUPPORT ANY ITEM MARKED UNDER THIS SECTION.

11. NARRATIVE JUSTIFICATION - (Please Be Precise In Your Explanation)

12. I hereby declare the information provided herein to be true and accurate to the best of my knowledge. I understand any false or misleading information may be considered a violation under Federal Acquisition Regulations.

Signature _________________________________________ Date: ___________________

Title: __________________________________________

Section Manager: ___________________________________ Date: ___________________ (Signature)

Typed Name: ______________________________________

FOR CONTRACTING OFFICE USE ONLY

APPROVED BY: ____________________________________ Date: ______________________ dawn.sullivan Cross-Out