Division of Purchasing

DIVISION OF PURCHASING

STATE OF FLORIDA Bureau of Procurement

DEPARTMENT OF 4050 Esplanade Way

Tallahassee, Florida 32399-0950

MANAGEMENT SERVICES <>

EXCEPTIONAL PURCHASE REQUEST

BLOCK BELOW & JUSTIFICATION BLOCK FOR AGENCY USE BELOW FOR DIVISION OF PURCHASING USE ONLY

______

FROM: (Department, Division, Bureau: Mailing Address)

AUTHORITY: ______

APPROVED/DENIED BY: ______

Authorized Signature

CONTACT PERSON: SUNCOM: Subject to approval by: ______

EMAIL ADDRESS FOR REPLY ______

AUTHORIZED SIGNATURE (Manual): Purchase shall not be made before this date: ______

CC: Auditor General

AUTHORIZED SIGNATURE (Typed): CHECK FOR ADDITIONAL COPIES:

DATE: TITLE: ____Communications ____ Comptroller's Office

VENDOR: ____Motor Pool

CLASS/GROUP NO.: PRICE:______VENDOR ______PREVIOUS APPROVAL # IF ANY ____

JUSTIFICATION (Use space below. Cover letter not required.) \ .

SINGLE SOURCE APPROVAL REQUEST

Submitted in accordance with Rule 60A-1.010, FAC

The following documents are attached to this request for DMS approval of a single source purchase:

(1) A copy of the advertisement in the Vendor Bid System, including posting start and end date.

(2)  A copy of the Single Source Description (including complete justification) posted in the attached or equivalent format on the Vendor Bid System with the advertisement, including start and end dates in accordance with s. 287.057(5)(c), FS,.

Responses received from other vendors during advertisement of the single source description: __ No __ Yes.

If yes, attach copies of vendor responses, and any written reply by the agency, with written explanation of the agency’s decision to continue with a single source acquisition.

Registration with Department of State (sunbiz.org)

___ Copy of Dept of State registration attached.

___ Copy of Dept of State registration not attached. Agency understands DMS will verify registration if copy is not attached, and reject single source purchase if vendor has not complied with statutory requirement for corporate registration (ref. Ch. 607 FS).

Registration in MyFloridaMarketPlace: ___ Yes ___ No

If “No” cite administrative rule authority for failure to register:

BELOW AND REVERSE SIDE FOR DIVISION OF PURCHASING USE ONLY