Drug Free Affidavit.pdf
PDF 78 KB Posted
- Attached to
- Dreamswork Field Sod Replacement
- Solicitation number
- RFB202690000686
- Issued by
- Mingo County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form (WV-73) required by the State of West Virginia under West Virginia Code 21-1D-5 for the Dreamswork Field Sod Replacement project in Morgantown, WV. The affidavit serves as a compliance document whereby an employee of the contracting company attests under oath that their employer maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The form requires completion of employee information, company name, printed signature, title, and the date of execution before a notary public.
The affidavit must be notarized with the notary's seal, printed name, title, commission expiration date, and signature. This document is a mandatory pre-award or pre-contract requirement for state and local contract opportunities in West Virginia and does not contain pricing information, contract terms, or project-specific deliverables. Contractors submitting bids for the sod replacement project must provide a completed and notarized affidavit as part of their proposal submission to demonstrate compliance with the state's drug-free workplace requirements.
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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: |
File details come from the government source that posted it. Updated .