Exhibit G - State of WV Drug Free Affidavit.pdf

77 KB Posted

Attached to
HSC North Elevator Modernization
Solicitation number
RFP202590000655
Issued by
West Virginia

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The document is a Drug Free Workplace Conformance Affidavit from the State of West Virginia, specifically form WV-73 approved on April 30, 2020. This standardized form is designed to ensure compliance with West Virginia Code §21-1D-5, requiring companies to attest to maintaining a written drug-free workplace policy. The form is part of the documentation for the HSC North Elevator Modernization project at West Virginia University, which involves modernizing traction elevators inside the Health Sciences Center North building.

The affidavit requires an authorized company representative to swear under penalty of perjury that their organization has a documented drug-free workplace policy that adheres to state regulations. The form must be completed, signed, and notarized, with spaces for the employee's name, company name, title, and date. While the document does not provide specific contract details or pricing, it represents a mandatory compliance requirement for businesses seeking to participate in state contract opportunities, ensuring workplace safety and regulatory adherence.

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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

Name:
Company Name2:
Printed Name:
Title:
Company Name:
Date:
COUNTY OF:
Day:
Month:
Year:
By Commission expires:

File details come from the government source that posted it. Updated .