Exhibit I - State of WV Drug Free Affidavit.pdf
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- Solicitation number
- RFP202690000697
- Issued by
- Mingo 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 for the Evansdale Crossing Third and Fourth Floor Renovations project in Morgantown, WV. The affidavit serves as a sworn statement in which an employee of the contracting company attests that their employer maintains a written drug-free workplace policy in compliance with West Virginia Code 21-1D. The document requires completion by a company representative who must provide their printed name, signature, title, company name, and date of execution.
The affidavit must be notarized before a West Virginia notary public, with the notary required to indicate the county, date of execution, and notary commission expiration date. This documentation is a standard compliance requirement for state contracts in West Virginia and ensures that contractors maintain workplace safety standards related to drug-free environments. The form (WV-73) was approved as of April 30, 2020, and represents a mandatory submission for bid qualification and contract award purposes.
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Text version
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: |
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