Drug Free Affidavit.pdf
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- Solicitation number
- ARFQ 0512 MMB2600000002 2
- Issued by
- Cabell County, West Virginia
About this file
This document is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia pursuant to West Virginia Code 21-1D-5. The affidavit must be completed and notarized by an employee of the bidding company to certify that the company maintains a valid written drug free workplace policy in compliance with West Virginia Code 21-1D. The affidavit requires the employee to provide their name, title, and company name, along with the date of sworn statement and notary public certification. Submission of this affidavit with the bid is mandatory to comply with state provisions.
Failure to include the completed and notarized Drug Free Workplace Conformance Affidavit with the bid submission will result in automatic disqualification of the bid. There are no pricing terms, set asides, or contract award information contained in this document, as it serves solely as a compliance verification form for bidders participating in West Virginia state and local contract opportunities.
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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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