Exhibit G - State of WV Drug Free Affidavit.pdf

77 KB Posted

Attached to
HSC South Elevator Modernization
Solicitation number
RFP202590000654
Issued by
West Virginia

About this file

Written by GovTribe AI ·

This document is a Drug Free Workplace Conformance Affidavit issued by the State of West Virginia, specifically designed to comply with West Virginia Code §21-1D-5. The form is a standardized template requiring an employee of a company to attest that their organization maintains a written drug-free workplace policy that adheres to state regulations. The affidavit is part of the documentation for the HSC South Elevator Modernization project at West Virginia University, which involves modernizing traction elevators in the Health Sciences Center South building.

The affidavit requires the signatory to swear under penalty of perjury that their company has a compliant drug-free workplace policy. The document must be completed, signed, and notarized, with spaces provided for the employee's name, company name, title, and date. The form was approved on April 30, 2020, with a revision date of July 7, 2017, and includes a section for a notary public to complete, including the county, date of signing, and notary commission expiration. This document appears to be a mandatory compliance requirement for contractors bidding on or performing work for the state of West Virginia.

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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 .