REQUEST FOR WAIVER PURCHASING

DORMITORY AUTHORITY - STATE OF NEW YORK
Office of Opportunity Programs
515 Broadway
Albany, NY 12207

A. TYPE OF WAIVER REQUEST ____ Total ____ Partial. If partial, complete blanks below:
MBE Waiver (%) requested _________ WBE Waiver (%) requested _________

B. CONTRACTOR/VENDOR
Firm _________________________________________________________________________
Address _________________________________________________________________________
City ________________________________State, Zip _______________________
Contact Person _________________________________
Telephone __________________________ Fax No. __________________________

C. PROJECT
Project ________________________________________________
P.O. Amount $ ____________ Address ________________________________________________
Bid Number ____________ ________________________________________________
Authority Goal MBE ____ (%) ________________________________________________
Authority Goal WBE_____ (%)

Work Description _________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

D. REQUIRED WAIVER INFORMATION DOCUMENTATION If the form does not provide adequate space for a complete response, attach additional pages as required to provide complete information.

1. Complete the following for certified minority- and women-owned business enterprises that were solicited in writing to provide services or bids on the Project identified above for purposes of complying with the Authority's goal requirements. Attach a copy of each solicitation for each certified firm listed. Attach a copy of each written solicitation response received from any minoity-owned business, MBE, or woman-owned business, WBE.

Firm Name___________________________________________ Date_________________ Address______________________________________________ Trade________________ City, State____________________________________________
Check certified firm type: Contact______________________________________________ ___MBE ___WBE

2. Attach documentation of any negotiations with any minority- and women-owned business enter- prises undertaken for purposes of complying with the AUTHORITY's goal requirements. ___Attachment(s) Provided ___Not Applicable

3. Provide a statement of justification to support the request for a waiver of the goal requirements established by the Authority.
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Type Name of Principal or Officer______________________________

Type Title of Principal or Officer_______________________________

Signature of Principal or Officer______________________________

Date _______________________________