Drug Free Affidavit.pdf
PDF 78 KB Posted
- Attached to
- Chestnut Ridge Building Roof Renovations
- Solicitation number
- RFB202690000722
- Issued by
- Mingo 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 for the Chestnut Ridge Building Roof Renovations project at West Virginia University in Morgantown, WV. The affidavit is a sworn statement in which an employee of the bidding company attests that their employer maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The form requires completion with the employee's printed name, signature, title, company name, and date, and must be notarized by a notary public who provides their printed name, title, date, and commission expiration information.
This document serves as a mandatory compliance certification that must be executed and submitted as part of the bid requirements for the roof replacement and repair project. The affidavit does not contain pricing information, project timelines, deliverables, or other contractual terms; rather, it functions solely as a prerequisite documentation requirement establishing that the contractor maintains a compliant drug-free workplace program as mandated by state law.
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Text version
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: |
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