Drug Free Affidavit.pdf

78 KB Posted

Attached to
PSC - Library Boiler Replacement
Solicitation number
RFB202690000713
Issued by
Mingo County, West Virginia

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This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia under West Virginia Code 21-1D-5 for the PSC - Library Boiler Replacement project at Potomac State College in Keyser, West Virginia. The affidavit serves as a sworn statement in which an employee of the bidding company attests that their organization maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The document requires completion by a company employee, including printed name, signature, title, company name, and date, followed by notarization before a notary public with official seal and commission expiration date.

This conformance affidavit is a mandatory compliance document that must be submitted as part of the bidding process for state and local contract opportunities in West Virginia. The affidavit does not address pricing, set-asides, or contract terms; rather, it establishes that the contractor meets the statutory requirement to maintain drug-free workplace policies as a prerequisite for contract award eligibility.

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Other files

File Type Posted
Attachment B - Specifications & Required Terms.pdf PDF
Attachment A - Bid Form & Pricing Information.pdf PDF
Contractor Safety Requirements November 2019.pdf PDF
RFB202690000713.pdf PDF
Project Manual.pdf PDF
1384865-event.pdf PDF
Contractor Safety Eval Pre-Qual Questionnaire.pdf PDF
Attachment D - Administration Building Boiler Package.pdf PDF
Purchasing Affidavit.pdf PDF
Attachment C - PSC Mary F. Shipper Library Boiler Package.pdf PDF
Certificate of Liability Insurance.pdf PDF
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WV-73

Approved / April 30, 2020

State of West Virginia

DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT

West Virginia Code §21-1D-5

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:

STATE OF WEST VIRGINIA,

COUNTY OF ____________________________, TO-WIT:

Taken, subscribed and sworn to before me this day of , .

By Commission expires

(Seal)

(Notary Public)

Rev. July 7, 2017

Printed Name:
Title:
Date:
COUNTY OF:
By Commission expires:
Day:
Month:
Year:
Name:
Company Name:
Company Name2:

File details come from the government source that posted it. Updated .