DRUG FREE AFFIDAVIT.pdf
PDF 81 KB Posted
- Solicitation number
- ARFQ-0313-DEP1700000072-3
- Issued by
- Raleigh County, West Virginia
About this file
The document is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia. It attests that the named company maintains a written plan for a drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be submitted with a bid in order to comply with state code provisions, and failure to include it will result in disqualification of the bid.
The related state and local contract opportunity is for the OSR Muddy Creek Restoration Project - Addendum #2, located in the state of West Virginia. No additional details about the project, such as quantities, response dates, or contract terms, are provided in the given information.
View the file
Other files
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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
| 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 .