Drug Free Affidavit.pdf

78 KB Posted

Attached to
One Waterfront Place Dry Coolers Replacement
Solicitation number
RFB202690000664
Issued by
Mingo County, West Virginia

About this file

Written by GovTribe AI ·

This is a Drug Free Workplace Conformance Affidavit form from the State of West Virginia, specifically related to West Virginia Code §21-1D-5. The form is designed for a company employee to attest that their organization maintains a written drug-free workplace policy that complies with state regulations. The document requires the employee to provide their personal details, company information, and sign the affidavit in the presence of a notary public, who will then validate the sworn statement.

The form is a standardized state document approved on April 30, 2020, with a revision date of July 7, 2017. It serves as a legal document requiring the signatory to confirm under penalty of perjury that their company has a drug-free workplace policy in accordance with state law. The form includes spaces for the employee's printed name, signature, title, company name, date, and requires official notarization with the county, date, and notary public's seal and signature to be completed.

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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 .