Equal Pay Undue Hardship Request for Authorization

EQUAL PAY UNDUE HARDSHIP REQUEST FOR AUTHORIZATION

Instructions: This form must be signed by the requesting agency head. Submit this form to the Commissioner of Administration in care of Betsy Hayes, Office of State Procurement, 112 Administration Building, St. Paul, MN 55155, or with a concurrent copy to the Minnesota Department of Human Rights at .

This is a request to authorize the execution of a contract with a contractor that does not have a current Equal Pay Certificate in accordance with Minnesota Statutes §363A.44, subdivision 1.

Agency Name: / Date:
Agency Contact: / Phone:
Contractor Name:
Describe the goods or services to be acquired under the contract:
Description of undue hardship that would occur to the agency or the state if the contract is not approved (attach additional documentation if needed):
REQUESTING AGENCY:
By signing below, I certify the information above is true and complete. I acknowledge that this request is not made solely for the convenience of the agency or due to lack of planning or preference for a particular product, brand or vendor.
Agency Head Signature: / ADMINISTRATION DEPARTMENT
 Approved without qualifications
 Approved with the following qualifications:
 Disapproved
Commissioner Signature:
Title: / Title:
Date: / Date:

Rev. 6/11/2015