ARFQ DCR2700000014 Drug Free Affidavit.pdf

PDF 81 KB Posted

Attached to
Resident Haircuts for J. M. Chick Buckbee Juvenile Center
Solicitation number
ARFQ 0608 DCR2700000014 1
Issued by
Kanawha County, West Virginia

About this file

Written by GovTribe AI ·

This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia for the Resident Haircuts contract opportunity at J. M. Chick Buckbee Juvenile Center. The affidavit is mandated under West Virginia Code 21-1D-5 and must be completed and notarized by an authorized company representative before submission with the bid. The document requires the affiant to confirm that their company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. Failure to submit this affidavit with the bid will result in automatic disqualification of the bidder's proposal.

The affidavit requires the following information: employee name and title, company name, county of execution, notarization by a commissioned notary public with current commission status, and the date of execution. The form includes fields for printed name, signature, company contact information, and notary seal. This document is a mandatory compliance requirement established by the State of West Virginia and represents a prerequisite condition for bid consideration on this contract opportunity.

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Other files

File Type Posted
ARFQ DCR2700000014 Specifications.pdf PDF
Final_ARFQ_0608_DCR2700000014_1_WV_ARFQ_FORM.PDF PDF
ARFQ DCR2700000014 Instructions To Vendors & Terms & Conditions.pdf PDF
ARFQ DCR2700000014 Pricing Page.xlsx XLSX spreadsheet

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State of West Virginia

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-1D-5

STATE OF WEST VIRGINIA,

COUNTY OF _______________, TO-WIT:

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: ______________________________________

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

By Commission expires _________________________

(Seal)

(Notary Public)

THIS AFFIDAVIT MUST BE SUBMITTED WITH THE BID IN ORDER TO COMPLY

WITH WV CODE PROVISIONS. FAILURE TO INCLUDE THE AFFIDAVIT WITH THE

BID SHALL RESULT IN DISQUALIFICATION OF THE BID.

Rev. August 1, 2015

WV-73

Approved / Revised 08/01/15

Printed Name:
Title:
Date:
County:
Vendor Name:
Company Name:
Company Name2:
day:
month:
year:
date of expiration:
Company Name3:

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