Exhibit I - State of WV Drug Free Affidavit.pdf

PDF 77 KB Posted

Attached to
Evansdale Crossing Third and Fourth Floor Renovations
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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