ARFQ DCR26_64- Drug Free Affidavit.pdf

PDF 78 KB Posted

Attached to
Resident Haircuts for Vicki V. Douglas Juvenile Center
Solicitation number
ARFQ-0608-DCR2600000064-1
Issued by
Berkeley County, West Virginia

About this file

Written by GovTribe AI ·

The document is a Drug Free Workplace Conformance Affidavit form from the State of West Virginia, specifically related to West Virginia Code §21-1D-5. The form requires an employee of a company to attest that their organization maintains a written drug-free workplace policy that is in compliance with the specified state code.

The affidavit is designed to be formally executed and notarized, with spaces for the employee's printed name, signature, title, company name, and date. The document includes a notary section where the affidavit can be officially sworn and recorded, with provisions for the county, date, and notary public's commission expiration. The form was approved on April 30, 2020, with a revision date of July 7, 2017, indicating ongoing updates to ensure regulatory compliance.

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Other files

File Type Posted
ARFQ DCR26_64- Specs - Barber - Vicki V. Douglas Juvenile Center.pdf PDF
ARFQ DCR26_64- Pricing Page Exhibit A - Barber - Vicki V. Douglas Juvenile Center.xlsx XLSX spreadsheet
Final_ARFQ_0608_DCR2600000064_1_WV_ARFQ_FORM.PDF PDF
Terms & Conditions - DCR.pdf PDF

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WV-73

Approved / April 30, 2020

State of West Virginia

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-1D-5

I, , after being first duly sworn, depose and state as follows:

1. I am an employee of ; and, (Company Name)

2. I do hereby attest that (Company Name) maintains a written plan for a drug-free workplace policy and that such plan and policy are in compliance with West Virginia Code §21-1D.

The above statements are sworn to under the penalty of perjury.

Printed Name:

Signature:

Title:

Company Name:

Date:

STATE OF WEST VIRGINIA,

COUNTY OF ____________________________, TO-WIT:

Taken, subscribed and sworn to before me this day of , .

By Commission expires

(Seal)

(Notary Public)

Rev. July 7, 2017

Printed Name:
Title:
Date:
COUNTY OF:
By Commission expires:
Day:
Month:
Year:
Name:
Company Name:
Company Name2:

File details come from the government source that posted it. Updated .