Drug Free Affidavit.pdf
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- Solicitation number
- ARFQ-0512-MMB2600000002-1
- Issued by
- Cabell County, West Virginia
About this file
This document is a Drug Free Workplace Conformance Affidavit from the State of West Virginia, specifically related to West Virginia Code §21-1D-5. The form requires an employee of a company to swear and attest that their organization maintains a valid written drug-free workplace policy that complies with the specified state code. The affidavit must be submitted with a bid, and failure to include it will result in bid disqualification.
The document is a standardized state form (WV-73) revised in August 2013, designed to be completed and notarized by a company representative. It requires the individual to provide their company name, affirm their employment, and confirm the existence of a drug-free workplace policy. The form includes spaces for the signatory's signature, title, company name, date, and requires notarization, with a clear warning that submission is mandatory for bid consideration under West Virginia state provisions.
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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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