Exhibit H - State of WV Drug Free Affidavit.pdf

77 KB Posted

Attached to
WVU Replacement Horse Barn
Solicitation number
RFP202690000660
Issued by
Monongalia County, West Virginia

About this file

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The document is a Drug Free Workplace Conformance Affidavit form for the State of West Virginia, specifically referencing West Virginia Code §21-1D-5. This standardized form requires an employee of a company to swear under penalty of perjury that their organization maintains a written drug-free workplace policy that complies with state regulations.

The form is designed to be completed by a company representative, who must fill in their personal details, company name, and provide a signature and notarization. The affidavit serves as an official attestation of the company's commitment to maintaining a drug-free workplace environment, as mandated by West Virginia state law. The document includes spaces for the individual's printed name, signature, title, company name, date, and requires notarization to validate the sworn statement.

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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 .