WV73 Drug Free Affidavit.pdf

PDF 83 KB Posted

Attached to
TRANSITIONAL LIVING FACILITY HVAC REPLACEMENT
Solicitation number
ARFQ 0512 WSH2700000005 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 Transitional Living Facility HVAC Replacement project. The affidavit is a mandatory compliance document that must be completed and submitted with any bid in response to this contract opportunity. The form requires an authorized employee of the bidding company to attest under oath that the company maintains a valid written drug-free workplace policy in compliance with West Virginia Code 21-1D. The affidavit must be notarized and include the employee's signature, title, company name, date, and the notary public's seal and commission expiration date. Failure to include the completed and notarized affidavit with a bid submission will result in automatic disqualification of that bid.

This affidavit serves as a prerequisite qualification document rather than a pricing or contractual terms document. All bidders are held to the same requirement with no exceptions or set-asides. The document was last revised in August 2013 and reflects West Virginia's statutory mandate under WV Code 21-1D-5 to ensure that companies bidding on state and local contracts operate drug-free workplaces. The affidavit does not address pricing, funding sources, contract duration, or renewal options, as it functions solely as a compliance verification mechanism prior to bid evaluation.

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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 .