ARFQ DEP18-52 DRUG FREE AFFIDAVIT.pdf
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- Solicitation number
- ARFQ 0313 DEP1800000052 3
- Issued by
- Preston County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form (WV-73) required by the State of West Virginia under West Virginia Code 21-1D-5. The document serves as a sworn attestation by an employee of a bidding company confirming that the company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be completed and notarized, with the affiant providing their printed name, signature, title, and the company name. The notary public must also execute the document by providing their printed name, title, date, commission expiration date, and official seal.
This form is a mandatory compliance documentation requirement for state contracts in West Virginia and does not contain pricing terms, contract amounts, or service specifications. Instead, it functions as a prerequisite certification that demonstrates the contractor's adherence to state drug-free workplace regulations. Contractors must submit this notarized affidavit as part of their bid package to establish eligibility for state and local contract opportunities in West Virginia.
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Text version
WV-73
Approved / July 7, 2017
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)
Rev. July 7, 2017
| Printed Name: |
| Title: |
| Date: |
| By Commission expires: |
| Day: |
| Month: |
| Year: |
| Name: |
| COUNTY: |
| Company Name: |
| Company Name 2: |
| Company Name 3: |
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