WV73 Drug Free Affidavit.pdf
PDF 83 KB Posted
- Attached to
- BOILER MAINTENANCE
- Solicitation number
- ARFQ 0512 WSH2700000003 1
- Issued by
- Kanawha County, West Virginia
About this file
This is a Drug Free Workplace Conformance Affidavit required by the State of West Virginia for the Boiler Maintenance contract opportunity. The affidavit is mandated under West Virginia Code 21-1D-5 and must be completed and notarized by an authorized company representative prior to bid submission. The document requires the affiant to confirm employment with the bidding company and attest that the company maintains a valid written drug free workplace policy in full compliance with West Virginia Code 21-1D. The affidavit must be signed, notarized with an official seal, and include the notary's commission expiration date.
Submission of the completed Drug Free Workplace Conformance Affidavit with the bid is a mandatory compliance requirement for the contract opportunity. Failure to include the notarized affidavit with the bid submission will result in automatic disqualification of the bid. The form has been in effect since August 2013 and represents a prerequisite condition for bid consideration under West Virginia state procurement regulations.
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Other files
| File | Type | Posted |
|---|---|---|
| Bid Bond Form.pdf | ||
| OSAFederalFundsContractClauseAddendum.pdf | ||
| Final_ARFQ_0512_WSH2700000003_1_WV_ARFQ_FORM.PDF | ||
| TCA.pdf | ||
| RFQ Specifications.docx | DOCX document | |
| BondPerform.pdf | ||
| Exhibit B.docx | DOCX document | |
| WV72 Drug Free Coversheet.pdf | ||
| WV36.pdf | ||
| Purchasing Affidavit.pdf | ||
| Exhibit A.xlsx | XLSX spreadsheet | |
| Bid Bond Instructions.pdf | ||
| BondLaborMat.pdf | ||
| Exhibit C.xlsx | XLSX spreadsheet | |
| WV43.pdf |
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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: |
File details come from the government source that posted it. Updated .