DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT.pdf
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- Solicitation number
- ARFQ 0512 MHC2500000001 4
- Issued by
- Marshall 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 affidavit serves as a certification document requiring an authorized employee of a contracting company to attest that their organization maintains a written drug-free workplace policy in accordance with West Virginia Code 21-1D. The form requires the deponent to provide their name, company name, title, and the date of execution. The affidavit must be notarized before a notary public, with the notary's seal, signature, and commission expiration date required for validity. This document is a mandatory compliance requirement for state and local contract opportunities in West Virginia.
No specific project details, pricing terms, quantities, response dates, or contract terms are contained in this affidavit form. The document functions solely as a standardized certification mechanism to ensure that companies bidding on or entering into contracts with the State of West Virginia demonstrate their commitment to maintaining drug-free workplace policies as mandated by state law. The form was approved on April 30, 2020, and last revised on July 7, 2017.
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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
File details come from the government source that posted it. Updated .