Drug Free Affidavit.pdf
PDF 67 KB Posted
- Solicitation number
- ARFQ 0608 DCR2500000028 1
- Issued by
- Tucker County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form issued by the State of West Virginia in compliance with West Virginia Code 21-1D-5. The document serves as a sworn attestation by an employee that their employing company maintains a written drug-free workplace policy and procedures that conform to West Virginia Code 21-1D requirements. The form requires completion of employee name, company name, title, and date, followed by notarization under penalty of perjury. This affidavit is a mandatory compliance document for state and local contracting purposes in West Virginia.
No pricing terms, set-asides, contract amounts, funding sources, or renewal options are specified in this document, as it functions solely as a compliance certification form rather than a contract solicitation or award document. The affidavit must be executed before a notary public and is effective as of the approval date of July 7, 2017.
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Other files
| File | Type | Posted |
|---|---|---|
| ARFQ 0608 DCR2500000028- Exhibit A Pricing Page.xlsx | XLSX spreadsheet | |
| ARFQ 0608 DCR2500000028 - Specifications.pdf | ||
| Final_ARFQ_0608_DCR2500000028_1_WV_ARFQ_FORM.PDF | ||
| ARFQ 0608 DCR2500000028 - Terms & Conditions.pdf |
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Text version
WV-73
Approved / July 7, 2017
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)
Rev. July 7, 2017
File details come from the government source that posted it. Updated .