DRUG FREE AFFIDAVIT.pdf
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- Attached to
- TO ATTACH ADDENDUM #2
- Solicitation number
- ARFQ 0512 MMB2500000005 3
- Issued by
- Cabell County, 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 affidavit is a mandatory compliance document that must be submitted with all bids to demonstrate that the bidding company maintains a valid written drug free workplace policy in compliance with West Virginia Code 21-1D. The affidavit requires an authorized company employee to swear under penalty of perjury that the company has implemented and maintains such a policy. The document must be notarized and include the notary's seal, signature, and commission expiration date.
Failure to submit the completed affidavit with a bid results in automatic disqualification of that bid. There are no pricing terms, set asides, or renewal options associated with this affidavit, as it is a mandatory compliance requirement rather than a standalone contract document. The affidavit form was last revised in August 2013 and is identified as form WV-73.
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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 valid written drug free workplace policy and that such policy is in compliance with West Virginia Code §21-1D.
The above statements are sworn to under the penalty of perjury.
By: ______________________________________
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 2013
WV-73
Rev. 08/2013
| COUNTY OF: |
| I: |
| I am an employee of: |
| I do hereby attest that: |
| Title: |
| Company Name: |
| Date: |
| Taken subscribed and sworn to before me this: |
| day of: |
| undefined_2: |
| By Commission expires: |
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