DEP1700000055 DRUG FREE AFFIDAVIT.pdf

81 KB Posted

Attached to
Addendum #2 Rife Branch Burning Refuse Pile Phase II
Solicitation number
ARFQ 0313 DEP1700000055 3
Issued by
Raleigh County, West Virginia

About this file

Written by GovTribe AI ·

This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia under West Virginia Code 21-1D-5. The affidavit must be completed and submitted with all bids to ensure contractor compliance with West Virginia's drug-free workplace policy requirements. The document requires an authorized company employee to attest under oath that their organization maintains a written drug-free workplace plan in full compliance with West Virginia Code 21-1D. The affidavit must be notarized and include the employee's printed name, signature, title, company name, date, and the notary public's seal and commission expiration date. Failure to submit this completed affidavit with a bid will result in automatic disqualification of that bid.

No pricing terms, contract amounts, or funding sources are specified in this document, as it serves solely as a compliance verification instrument. The affidavit form was approved and revised on August 1, 2015, and applies to all vendors bidding on West Virginia state and local contract opportunities. There are no set asides, incumbent considerations, or renewal options outlined in this document.

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DEP1700000055 INSTRUCTIONS TO BIDDER.pdf PDF
DEP1700000055 DEP PROCUREMENT AFFIDAVIT.pdf PDF
Final_ARFQ_0313_DEP1700000055_3_ARFQ_FORM.PDF PDF
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DEP1700000055 BID BOND FORM WITH INSTRUCTIONS-1.pdf PDF
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DEP1700000055 DEP AVS.pdf PDF
Addendum #2 DEP1700000055 Rife Branch Burning Refuse Pile Phase II.pdf PDF
Rife Branch Burning Refuse Pile Phase II SHEET SET - FINAL.pdf PDF
Final_ARFQ_0313_DEP1700000055_1_ARFQ_FORM.PDF PDF
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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 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

Printed Name:
Title:
Date:
County:
Vendor Name:
Company Name:
Company Name2:
day:
month:
year:
date of expiration:
Company Name3:

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