ARFQ WEH2500000007 WV Druf Free Workplace Affidavit.pdf

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Attached to
HVAC UNIT (LABORATORY DEPARTMENT)
Solicitation number
ARFQ 0512 WEH2500000007 3
Issued by
Mineral County, West Union Town, 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 WEH2500000007. The affidavit must be completed and submitted with all bids as a mandatory compliance requirement. The form requires an authorized company employee to attest under oath that their organization maintains a valid written drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be notarized and include the employee's title, company name, date of execution, and the notary public's commission expiration date. Failure to include the completed and notarized affidavit with the bid submission will result in automatic disqualification of the bid.

No pricing terms, contract duration, renewal options, or service specifications are contained in this affidavit document. This form serves solely as a conformance certification mechanism established by West Virginia state law to ensure bidders maintain drug-free workplace policies as a prerequisite for contract eligibility. The affidavit was last revised in August 2013.

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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 valid written drug free workplace policy and that such policy is in compliance with West Virginia Code §21-1D.

The above statements are sworn to under the penalty of perjury.

By: ______________________________________

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 2013

WV-73

Rev. 08/2013

COUNTY OF:
I:
I am an employee of:
I do hereby attest that:
Title:
Company Name:
Date:
Taken subscribed and sworn to before me this:
day of:
undefined_2:
By Commission expires:

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