ARFQ DEP21-55 Drug-Free Affidavit.pdf
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- Solicitation number
- ARFQ 0313 DEP2100000055 2
- Issued by
- Taylor 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 form serves as a compliance document for contract opportunities in West Virginia and requires an authorized employee of a bidding company to attest that the organization maintains a written drug-free workplace policy in accordance with West Virginia Code 21-1D. The affidavit must be completed with the employee's printed name, signature, title, company name, and date, and must be notarized by a notary public who provides their name, commission expiration date, and county of commission.
No pricing terms, set asides, incumbents, funding sources, or contract renewal options are specified in this document. The affidavit functions as a mandatory compliance certification rather than a substantive contract document outlining services, quantities, response dates, or award information. Completion and submission of this notarized form is a prerequisite requirement for bidders on West Virginia state and local contract opportunities, ensuring that all participating vendors maintain drug-free workplace standards.
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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: |
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