DEP1700000006 DRUG FREE AFFIDAVIT.pdf
PDF 92 KB Posted
- Attached to
- Addendum No. 2 Lyburn (Maynard) Drainage
- Solicitation number
- ARFQ 0313 DEP1700000006 3
- Issued by
- Lincoln 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. The affidavit serves as a mandatory compliance document for bidders on state contracts and must be submitted with all bids to meet state legal requirements.
The affidavit requires a company employee to attest under oath, before a notary public, that their organization maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The document must be completed with the affiant's printed name, signature, title, company name, date of execution, and notarization details including the notary's commission expiration date. Failure to include the completed affidavit with a bid submission results in automatic bid disqualification. The form was approved and last revised on August 1, 2015.
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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
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