DrugFreeAff.pdf
PDF 83 KB Posted
- Attached to
- Addendum 01 MAXWELL #1 WELL PLUGGING
- Solicitation number
- CRFQ 0313 DEP1600000033 2
- Issued by
- Fayette County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia in compliance with West Virginia Code 21-1D-5. The affidavit must be completed and submitted with all bids to demonstrate that the bidding company maintains a valid written drug-free workplace policy in accordance with West Virginia Code 21-1D. The document requires an employee of the bidding company to attest under oath that the company maintains such a policy. Failure to include the completed affidavit with a bid submission will result in automatic disqualification of that bid. The affidavit must be notarized and include the signature and title of the attesting employee, the company name, date of execution, and the notary public's seal and commission expiration date.
This affidavit serves as a mandatory compliance requirement for state procurement processes and does not contain pricing information, set-asides, contract terms, funding amounts, or other financial details. It is a prerequisite document that establishes the contractor's commitment to maintaining workplace drug policies as mandated by West Virginia state law.
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Text version
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 valid written drug free workplace policy and that such policy is in compliance with West Virginia Code §21-1D.
The above statements are sworn to under the penalty of perjury.
By: ______________________________________
Title: ______________________________________
Company Name: ________________________________
Date: ______________________________________
Taken, subscribed and sworn to before me this _____ day of ____________, _________.
By Commission expires _________________________
(Seal)
(Notary Public)
THIS AFFIDAVIT MUST BE SUBMITTED WITH THE BID IN ORDER TO COMPLY
WITH WV CODE PROVISIONS. FAILURE TO INCLUDE THE AFFIDAVIT WITH THE
BID SHALL RESULT IN DISQUALIFICATION OF THE BID.
Rev. August 2013
WV-73
Rev. 08/2013
| COUNTY OF: |
| I: |
| I am an employee of: |
| I do hereby attest that: |
| Title: |
| Company Name: |
| Date: |
| Taken subscribed and sworn to before me this: |
| day of: |
| undefined_2: |
| By Commission expires: |
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