WV73 Drug Free Affidavit (1).pdf
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- Attached to
- Concrete Pad, Fencing and bollard Replacement
- Solicitation number
- ARFQ-0512-WEH2500000014-2
- Issued by
- Mineral County, West Virginia
About this file
This document is a Drug Free Workplace Conformance Affidavit for the State of West Virginia, specifically complying with West Virginia Code §21-1D-5. The form requires an employee of a company to swear under penalty of perjury that their organization maintains a valid written drug-free workplace policy in compliance with state regulations. This affidavit is a mandatory submission requirement for bidders on state contracts, with explicit instructions that failure to include the completed document with a bid will result in automatic disqualification.
The affidavit is a standardized state form (WV-73) revised in August 2013, designed to ensure that businesses seeking state contracts adhere to workplace drug policy standards. The document must be signed by an authorized company representative, notarized, and includes fields for the company name, title of the signatory, date, and notary public details. The form underscores West Virginia's commitment to maintaining drug-free work environments as a condition for participating in state procurement processes.
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Text version
State of West Virginia
DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT
West Virginia Code §21-1D-5
STATE OF WEST VIRGINIA,
COUNTY OF _______________, TO-WIT:
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 valid written drug free workplace policy and that such policy is in compliance with West Virginia Code §21-1D.
The above statements are sworn to under the penalty of perjury.
By: ______________________________________
Title: ______________________________________
Company Name: ________________________________
Date: ______________________________________
Taken, subscribed and sworn to before me this _____ day of ____________, _________.
By Commission expires _________________________
(Seal)
(Notary Public)
THIS AFFIDAVIT MUST BE SUBMITTED WITH THE BID IN ORDER TO COMPLY
WITH WV CODE PROVISIONS. FAILURE TO INCLUDE THE AFFIDAVIT WITH THE
BID SHALL RESULT IN DISQUALIFICATION OF THE BID.
Rev. August 2013
WV-73
Rev. 08/2013
| COUNTY OF: |
| I: |
| I am an employee of: |
| I do hereby attest that: |
| Title: |
| Company Name: |
| Date: |
| Taken subscribed and sworn to before me this: |
| day of: |
| undefined_2: |
| By Commission expires: |
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