Drug Free Affidavit.pdf
PDF 82 KB Posted
- Solicitation number
- ARFQ-0512-MMB2600000002-2
- 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 attest that their organization maintains a valid written drug-free workplace policy that complies with state regulations. Submission of this completed and notarized affidavit is mandatory with bid documents, and failure to include it will result in automatic disqualification of the bid.
The affidavit serves as a sworn statement under penalty of perjury, requiring the company representative to sign and have the document notarized, confirming their workplace drug policy meets state standards. The form was revised in August 2013 and is identified as form WV-73, featuring the official seal of West Virginia. It provides spaces for the company name, representative's signature, title, date, and notary public certification, emphasizing the legal and compliance aspects of maintaining a drug-free workplace for state contract opportunities.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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: |
File details come from the government source that posted it. Updated .