Drug Free Workplace Affidavit - ARFQ DCR24-78.pdf
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- Attached to
- PM Kitchen - NCRJ
- Solicitation number
- ARFQ 0608 DCR2400000078 1
- Issued by
- Fayette 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, applicable to contract opportunity ARFQ DCR24-78. The affidavit serves as a sworn statement in which an employee of a bidding company attests that their organization maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The document requires completion by a company employee who must provide their name, title, company name, and signature, with the affidavit subsequently notarized by a public notary. This form is a compliance requirement for state and local contracting opportunities in West Virginia and must be submitted as part of the bidding process.
No specific pricing terms, set-asides, incumbent information, funding sources, or contract performance dates are addressed in this affidavit document. The form is administrative in nature and solely establishes the bidder's confirmation of maintaining a drug-free workplace policy as mandated by West Virginia state law. Submission of this completed and notarized affidavit is a prerequisite to bid eligibility rather than a substantive contract deliverable.
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Text version
WV-73
Approved / July 7, 2017
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 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:
Taken, subscribed and sworn to before me this day of , .
By Commission expires
(Seal)
(Notary Public)
Rev. July 7, 2017
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| Title: |
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| By Commission expires: |
| Day: |
| Month: |
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| Name: |
| COUNTY: |
| Company Name: |
| Company Name 2: |
| Company Name 3: |
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