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

Printed Name:
Title:
Date:
By Commission expires:
Day:
Month:
Year:
Name:
COUNTY:
Company Name:
Company Name 2:
Company Name 3:

File details come from the government source that posted it. Updated .