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
The document is a Drug Free Workplace Conformance Affidavit from the State of West Virginia, specifically related to compliance with West Virginia Code §21-1D-5. This standard form requires bidders on state contracts to affirm that their company maintains a valid written drug-free workplace policy that adheres to state regulations. The affidavit must be submitted with the bid, and failure to include it will result in automatic disqualification of the bid.
The affidavit requires an authorized company representative to swear under penalty of perjury that their organization has a drug-free workplace policy in compliance with state law. The document must be completed, signed, and notarized, with the notary public providing an official seal and recording the date of attestation. This form is a mandatory administrative requirement for businesses seeking to contract with the State of West Virginia, designed to ensure workplace safety and drug-free work environments across state-funded projects and contracts.
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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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