DEP1700000030 DRUG FREE AFFIDAVIT.pdf
PDF 81 KB Posted
- Attached to
- Addendum No 1 Grafton #4 Refuse and Highwall
- Solicitation number
- ARFQ 0313 DEP1700000030 2
- Issued by
- Ritchie County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form required by the State of West Virginia in compliance with West Virginia Code 21-1D-5. The affidavit must be completed and submitted with all bids to confirm that the bidding company maintains a written drug-free workplace policy in accordance with state requirements. The form requires a company employee to attest under oath that their employer has established and maintains a compliant drug-free workplace plan. Failure to include the completed and notarized affidavit with a bid submission will result in automatic disqualification of that bid.
The affidavit must be notarized before submission and includes fields for the employee's printed name, signature, title, company name, date, and the notary public's seal and expiration date. This document serves as a mandatory compliance verification rather than a pricing or service specification document, establishing that bidders meet West Virginia's drug-free workplace statutory requirements as a condition of bid eligibility.
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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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| Company Name2: |
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| Company Name3: |
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