DRUG FREE WORKPLACE AFFIDAVIT-ARFQ DEP2100000019.pdf
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- Solicitation number
- ARFQ 0313 DEP2100000019 7
- Issued by
- Wetzel County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit form (WV-73) issued by the State of West Virginia in compliance with West Virginia Code 21-1D-5. The form requires an authorized employee of a bidding or contracting company to attest under oath that their organization maintains a written drug-free workplace policy and plan that complies with West Virginia Code 21-1D. The affidavit must be notarized and include the employee's printed name, signature, title, company name, and date of execution. The notary public must also complete their section with printed name, title, commission expiration date, and official seal.
This affidavit document serves as a compliance requirement for state and local contract opportunities in West Virginia. Bidders and contractors are required to submit this sworn statement as part of their proposal or contracting process to demonstrate adherence to drug-free workplace standards mandated by state law. The form was approved and became effective on July 7, 2017, and represents a mandatory certification rather than a pricing, funding, or service-related document.
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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: |
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