DRUG FREE AFFIDAVIT.pdf
PDF 139 KB Posted
- Attached to
- Addendum 4 Tony's Exxon UST removal Logan County
- Solicitation number
- ARFQ 0313 DEP1900000091 5
- Issued by
- Lewis County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form (WV-73) issued by the State of West Virginia in compliance with West Virginia Code 21-1D-5. The document serves as an attestation form that requires an employee of a contracting company to swear under penalty of perjury that their employer maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The form must be completed by an employee of the company seeking state contracts, signed, notarized, and submitted as part of the contracting process.
The affidavit requires specific information including the employee's printed name, signature, title, company name, and date of execution. A notary public must witness the sworn statement, provide their printed name, title, and notary commission expiration date, and affix their seal. The form also includes fields for multiple company names and county information. This affidavit is a mandatory compliance document for state contracting purposes and demonstrates that the bidding company meets West Virginia's drug-free workplace requirements as a condition of eligibility for state and local contract opportunities.
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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
| Printed Name: |
| Title: |
| Date: |
| By Commission expires: |
| Day: |
| Month: |
| Year: |
| Name: |
| COUNTY: |
| Company Name: |
| Company Name 2: |
| Company Name 3: |
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