Drug Free Affidavit.pdf
PDF 78 KB Posted
- Solicitation number
- RFB202690000696
- Issued by
- Mingo County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia under West Virginia Code 21-1D-5 for the PRT Guideway Bridge Bearing Replacement and Pier Repair project at West Virginia University in Morgantown. The affidavit serves as a compliance document for contractors and employees working on state and local contracts. The form requires a sworn statement from an employee attesting that their company maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be notarized and submitted with the company name, employee name and title, date, and signature of both the affiant and notary public.
This document is a mandatory compliance requirement for all bidders and contractors on West Virginia state and local contract opportunities. There are no pricing terms, set-asides, or financial requirements associated with the affidavit itself; rather, it functions as a prerequisite certification demonstrating the contractor's commitment to maintaining a drug-free workplace as a condition of contract eligibility. All firms seeking to work on this WVDOT bridge bearing and pier repair project must complete and submit this notarized affidavit as part of their proposal package.
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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: |
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