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 Form WV-73, a Drug Free Workplace Conformance Affidavit required by the State of West Virginia under West Virginia Code §21-1D-5, approved April 30, 2020. The document requires company employees to attest that their organization maintains a written drug-free workplace policy and that such policy complies with West Virginia Code §21-1D. The form must be completed under penalty of perjury and requires the employee's printed name, signature, title, company name, and date.
The document must be notarized, requiring completion before a Notary Public with the county specified, dated, and sealed. The form includes spaces for the notary's commission expiration date and signature. This is a standard compliance document that would typically be required as part of a broader submission for state contracting or regulatory compliance purposes in West Virginia.
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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 .