ARFQ DCR2700000017 Drug Free Affidavit.pdf
PDF 81 KB Posted
- Solicitation number
- ARFQ 0608 DCR2700000017 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 under West Virginia Code 21-1D-5 for contract opportunity ARFQ DCR2700000017 related to resident haircuts for Kenneth "Honey" Rubenstein J.C. The affidavit must be completed and submitted with all bids to demonstrate compliance with West Virginia's drug-free workplace requirements. The document requires an authorized company employee to attest under penalty of perjury that their organization maintains a written drug-free workplace policy compliant with West Virginia Code 21-1D. The affidavit must be notarized and include the employee's printed name, signature, title, company name, and date, along with the notary public's commission expiration date and official seal.
Submission of this affidavit is mandatory for bid eligibility. Failure to include the completed and notarized affidavit with the bid submission will result in automatic disqualification of the bid. The affidavit form was approved and revised on August 1, 2015, and serves as the state's mechanism for ensuring all contractors maintain drug-free workplace standards as a condition of contract award.
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Other files
| File | Type | Posted |
|---|---|---|
| ARFQ DCR2700000017 Specifications.pdf | ||
| Final_ARFQ_0608_DCR2700000017_1_WV_ARFQ_FORM.PDF | ||
| ARFQ DCR2700000017 Instructions To Vendors & Terms & Conditions.pdf | ||
| ARFQ DCR2700000017 Pricing Page .xlsx | XLSX spreadsheet |
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Text version
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
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