ARFQ DCR27 12 Drug Free Affidavit.pdf
PDF 78 KB Posted
- Solicitation number
- ARFQ 0608 DCR2700000012 1
- Issued by
- Kanawha County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia for the Resident Haircuts contract opportunity with Eastern Regional Jail & Corrections. The affidavit, form WV-73, is mandated under West Virginia Code 21-1D-5 and must be completed and sworn by an authorized employee of the bidding contractor. The document requires the employee to attest that the company maintains a written drug-free workplace policy that complies with West Virginia Code 21-1D.
The affidavit must be notarized before a notary public and includes fields for the employee's printed name, signature, title, company name, and date of execution. The notary section requires the notary's printed name, title, date, county of commission, and commission expiration date. This form represents a mandatory compliance requirement for any contractor bidding on this state and local contract opportunity and must be submitted as part of the proposal package.
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Text version
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 .