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#A <br /> 5 <br /> REQUEST FOR SOLE SOURCE <br /> To: Purchasing Office <br /> From: Murray Gordon / Fire <br /> Name of Department Head Dept./Division <br /> Subject: Sole Source Request for the Purchase Of: LifePak 15 version 2 cardiac <br /> Monitor/Debfibrillator <br /> REQUESTED SUPPLIER: Medtronic/Physio Control <br /> REQUISITION NUMBER: P O/7 6) D COST ESTIMATE: $108,912.57 <br /> Sole source purchases are defined as clearly and legitimately limited to a single supplier. Sole source <br /> purchases are normally not allowed except when based upon strong technological grounds such as <br /> operational compatibility with existing equipment and related parts or upon a clearly unique and cost <br /> effective feature requirement. The use of sole source purchases shall be limited only to those specific <br /> instances which are totally justified to satisfy compatibility or technical performance needs. <br /> STATEMENT OF NEED: <br /> My department's recommendation for sole source is based upon an objective review of the product/service <br /> required and appears to be in the best interest of the City. I know of no conflict of interest on my part or <br /> personal involvement in any way with this request. No gratuities,favors or compromising action have taken <br /> place. Neither has my personal familiarity with particular brands, types of equipment, materials or firms <br /> been a deciding influence on my request to sole source this purchase when there are other known suppliers to <br /> exist. <br /> Refer to the attached sole source justification as prepared by our department, to the attached review of , <br /> available products/services and to my completed Purchase Requisition. <br /> Requestor Department Head <br /> 0, Approved ❑Rejected <br /> ,4fI - -- / $-&r -I1 0-•j 1. '41 ` / ..c.--dc-// <br /> IggnatureoRequestor. Date Signature of Dept. ead Date <br /> If Purchase is$10,000 or more: If Purchase is$50,000 or more: <br /> Purchasing Manager City Attorney <br /> I. Approved ❑Rejected [ pproved El]Rejected <br /> • <br /> signature o'Purchasing Manager Dat ignature of City Attorney Date <br /> . <br /> s:/#common/forms/sole <br /> 13 <br />