DEP1700000053 DRUG FREE AFFIDAVIT.pdf
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- Attached to
- Addendum #2 Oldhouse Branch Refuse Pile
- Solicitation number
- ARFQ 0313 DEP1700000053 3
- Issued by
- Nitro City, 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 document is a sworn statement that must be completed by an employee of the bidding company and notarized before submission. The affidavit confirms that the company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. Submission of the completed and notarized affidavit with the bid is mandatory; failure to include it will result in automatic disqualification of the bid.
The affidavit requires the deponent to provide their name, title, and company name, along with the company representative's printed name, signature, and date. A notary public must witness the sworn statement and provide their commission expiration date. This compliance document is a prerequisite requirement for participation in State of West Virginia procurement processes and reflects the state's commitment to maintaining drug-free workplaces among its contractors and vendors.
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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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