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    Human Relations Commission Certified Vendors

    Uploaded by

    WAVE 3 News
    This document is a contract request form for Louisville Metro Government. It provides information about the contract such as the department and contact details, contract type, requested dates, vendor details including legal name and address, payment details, and justification for sole source contracts. The form requires signatures from the department director and purchasing director to approve the contract.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Human Relations Commission Certified Vendors

    Uploaded by

    WAVE 3 News
    51 views5 pages
    This document is a contract request form for Louisville Metro Government. It provides information about the contract such as the department and contact details, contract type, requested dates, vendor details including legal name and address, payment details, and justification for sole source contracts. The form requires signatures from the department director and purchasing director to approve the contract.

    Original Description:

    City document approving removal purchase

    Original Title

    2

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    © © All Rights Reserved

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    This document is a contract request form for Louisville Metro Government. It provides information about the contract such as the department and contact details, contract type, requested dates, vendor details including legal name and address, payment details, and justification for sole source contracts. The form requires signatures from the department director and purchasing director to approve the contract.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    51 views5 pages

    Human Relations Commission Certified Vendors

    Uploaded by

    WAVE 3 News
    This document is a contract request form for Louisville Metro Government. It provides information about the contract such as the department and contact details, contract type, requested dates, vendor details including legal name and address, payment details, and justification for sole source contracts. The form requires signatures from the department director and purchasing director to approve the contract.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    DocuSign Envelope ID: 0068A485-FEF1-4B7D-9B87-578366AC5E17

    Department Department Contact


    Contact Email Contact Phone

    Contract Type: check one


    Additional
    Time Extension Scope
    Funds
    Professional Service
    Sole Source (goods/services)

    Requested Contract Dates (MM/DD/YYYY)

    Vendor Legal Name


    DBA
    Point of Contact Email
    Street
    Suite/Floor/Apt Phone
    City State Zip Code

    Federal Tax ID# SSN# (If sole proprietor)


    Louisville Revenue Commission Account #
    Certified Minority Certified Woman Disabled Owned
    Human Relations Commission Certified Vendors
    Owned Business Owned business business
    Select if applicable

    Not to Exceed Contract Amount (including reimbursement expenses, if applicable)

    Fund Source General Fund


    Federal Grant Federal Granting Agency
    Other Describe:
    Account Code String #

    per hour per day per service


    per month Other

    Monthly Upon Completion / Delivery


    Quarterly Other

    Page of
    DocuSign Envelope ID: 0068A485-FEF1-4B7D-9B87-578366AC5E17

    (Attach additional documentation if necessary)


    Describe the circumstances under which a time extension or scope change is needed.
    Be specific about the work to be performed / product to be purchased including but not limited to: scope of work; description of
    service; work product created; why the service / product is necessary; and benefit to Louisville Metro Government.

    (Attach additional documentation if necessary)


    Provide justification including but not limited to: a description of the unique features that prohibit competition; research conducted to
    verify the vendor as the only known source (sole source); why the service (PSC) is not feasible to be provided by LMG staff or expertise
    does not exist; known compatibility, proprietary and/or timing issues.

    Per KRS 45A.380, I have determined that competition is not feasible for the above described good / service and
    there is a single source within a reasonable geographical area of the good / service to be procured; or the resulting contract is for the
    services of a licensed professional, technician, artist, or other non-licensed professional service.

    Department Director_________________________________________________ Date________________


    Signature
    ______________________________________________________________
    Printed Name

    Purchasing Director ___________________________________________________ Date________________


    Signature
    _________________________________________________________
    Joel Neaveill

    Page of
    DocuSign Envelope ID: 0068A485-FEF1-4B7D-9B87-578366AC5E17
    DocuSign Envelope ID: 0068A485-FEF1-4B7D-9B87-578366AC5E17
    DocuSign Envelope ID: 0068A485-FEF1-4B7D-9B87-578366AC5E17

    8/18/2020

    Jeff O'Brien

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