DrugFreeAff.pdf
PDF 81 KB Posted
- Attached to
- BARBER SERVICE FOR TVRJ
- Solicitation number
- ARFQ 0608 RJC2200000008 1
- Issued by
- Barbour County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia under West Virginia Code 21-1D-5. The affidavit must be completed and submitted by a company employee who attests that their employer maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The document requires the affiant to provide their printed name, signature, title, company name, and date, and must be notarized with the notary public's commission expiration date included. Submission of this affidavit is mandatory with all bids submitted to the State of West Virginia.
Failure to include the completed and notarized Drug Free Workplace Conformance Affidavit with a bid submission will result in automatic disqualification of that bid. The affidavit serves as a compliance verification mechanism ensuring that bidding contractors meet West Virginia's drug-free workplace requirements as a condition of eligibility to conduct state business. This document was revised and approved on August 1, 2015.
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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 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)
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 1, 2015
WV-73
Approved / Revised 08/01/15
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