Attachment_E_-_Drug_Free_Workplace.pdf

PUR-F-304 Rev 3/2018

City of Casselberry | Finance Department | Procurement Division 95 Triplet Lake Drive, Casselberry, Florida 32707

Phone: 407-262-7700, Ext. 1142 | Fax: 407-262-7746

Solicitation Number:

2018-0369

REQUEST FOR PROPOSALS (RFP)

Due Date:

August 10, 2018

TITLE: Property and Casualty Insurance

Attachment “E”

Drug-Free Workplace Certification

When applicable, the drug-free certification form below must be signed and returned with the RFP response.

In order to have a drug-free workplace program, a business shall:

A. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

B. Inform employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

C. Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in the first paragraph.

D. In the statement specified in the first paragraph, notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893, Florida Statutes, or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

E. Impose a sanction on, or require the satisfactory participation in, a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted.

F. Make a good faith effort to continue to maintain a drug-free workplace through implementation of the foregoing provisions.

By the signature(s) below, I/we, the undersigned, as authorized signatory to commit the firm, certify that the information as provided in Attachment “D”, Drug-Free Workplace Certification, is truthful and correct at the time of submission.

AUTHORIZED SIGNATURE

Typed Name of AUTHORIZED SIGNATORY

Title

STATE OF ________________

COUNTY OF ________________

The foregoing instrument was executed before me this ____ day of _______________, 20___, by

________________________________as________________________of_____________________________________, PUR-F-304 Rev 3/2018

City of Casselberry | Finance Department | Procurement Division 95 Triplet Lake Drive, Casselberry, Florida 32707

Phone: 407-262-7700, Ext. 1142 | Fax: 407-262-7746

Solicitation Number:

REQUEST FOR PROPOSALS (RFP)

Due Date:

who personally swore or affirmed that he/she is authorized to execute this document and thereby bind the Corporation, and who is personally known to me OR has produced ___________________ as identification.

NOTARY PUBLIC, State of ____________

(stamp)

PLEASE COMPLETE AND SUBMIT WITH YOUR RFP RESPONSE – (if applicable)

TITLE: Property and Casualty Insurance

2018-0369

August 10, 2018