Drug Free Workplace Affidavit ARFQ DEP2000000007.pdf
PDF 139 KB Posted
- Attached to
- Addendum No. 01 Lake (Bell) Portals)
- Solicitation number
- ARFQ 0313 DEP2000000007 2
- Issued by
- Lincoln County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form required by the State of West Virginia under West Virginia Code 21-1D-5, applicable to state and local contract opportunities in West Virginia. The form serves as an attestation document that must be completed and sworn before a notary public by an employee of a contracting company. The affidavit certifies that the company maintains a written drug-free workplace policy and plan that complies with West Virginia Code 21-1D requirements. The form requires the deponent to provide their name, title, company name, and the date of the sworn statement, along with notarization including the notary's printed name, title, commission expiration date, and seal.
This document is a compliance requirement rather than a solicitation or contract award notice. No pricing terms, contract amounts, or service deliverables are specified in the affidavit itself, as it functions solely as a certification mechanism. The form must be completed and notarized as part of the proposal or contract submission process for any entity bidding on state or local contracts in West Virginia. There are no renewal options, set asides, or incumbent information associated with this standalone compliance document.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .