DRUG FREE AFFIDAVIT ARFQ DEP25-20.pdf

77 KB Posted

Attached to
AML - Ethel Hollow Phase II Site A
Solicitation number
ARFQ 0313 DEP2500000020 3
Issued by
Lincoln County, West Virginia

About this file

Written by GovTribe AI ·

This is a Drug Free Workplace Conformance Affidavit form issued by the State of West Virginia under West Virginia Code 21-1D-5. The affidavit requires an authorized employee of a contracting company to attest under penalty of perjury that the company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The form must be completed with the employee's printed name, signature, title, company name, and date, and requires notarization by a notary public with the notary's printed name, title, commission expiration date, and county designation.

This document serves as a mandatory compliance requirement for state and local contract opportunities in West Virginia. Bidders and contractors must submit a completed and notarized affidavit as part of their proposal to demonstrate workplace drug policy compliance. The form was approved on April 30, 2020, and revised on July 7, 2017. No pricing, funding, or contract term information is specified in this affidavit form, as it functions solely as a certification document rather than a procurement specification or award notice.

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Other files

File Type Posted
AVS FORM ARFQ DEP25-20 ETHEL HOLLOW PHASE II SITE A.pdf PDF
DEP CONSTRUCTION BID SUBMISSION FORMS ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
Final_ARFQ_0313_DEP2500000020_3_WV_ARFQ_FORM.PDF PDF
DISCLOSURE OF INTERESTED PARTIES ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
CONSTRUCTION SPECIFICATIONS ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
DEP INSTRUCTIONS AND TERMS AND CONDITIONS CONSTRUCTION ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
ADDENDUM 2 ARFQ DEP25-20 ETHEL HOLLOW PHASE II SITE A.pdf PDF
Final_ARFQ_0313_DEP2500000020_1_WV_ARFQ_FORM.PDF PDF
DLR SUPPLEMENTAL SPECIFICATIONS ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
PLANS ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
Final_ARFQ_0313_DEP2500000020_2_WV_ARFQ_FORM.PDF PDF
ADDENDUM NO 1 ARFQ DEP25-20 ETHEL HOLLOW.pdf PDF
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WV-73

Approved / April 30, 2020

State of West Virginia

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-1D-5

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:

STATE OF WEST VIRGINIA,

COUNTY OF ____________________________, TO-WIT:

Taken, subscribed and sworn to before me this day of , .

By Commission expires

(Seal)

(Notary Public)

Rev. July 7, 2017

Printed Name:
Title:
Date:
COUNTY OF:
By Commission expires:
Day:
Month:
Year:
Name:
Company Name:
Company Name2:

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