ARFQ DEP1800000004 DRUG FREE AFFIDAVIT.pdf

PDF 92 KB Posted

Attached to
Addendum 1 Muddy Creek Project 4 Gravity UO-519, S-91-85
Solicitation number
ARFQ 0313 DEP1800000004 2
Issued by
Raleigh 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 bid submissions to state and local contract opportunities. The affidavit serves as a mandatory compliance document that must be completed by an employee of the bidding company and submitted with all bids. The document requires the affiant to attest that their company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be notarized and includes fields for the employee's printed name, signature, title, company name, date, and notary public information. No specific contract term, renewal options, or project details are outlined in this document.

Failure to submit the completed affidavit with a bid submission results in automatic disqualification. There are no pricing terms, set-asides, or funding amounts specified in this conformance document, as it functions solely as a compliance verification form required for all bidders. The affidavit was last revised on August 1, 2015, and applies uniformly to all state and local contract opportunities subject to West Virginia's drug-free workplace requirements.

View the file

Other files

Show all 11

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

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

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 .