WV73 Drug Free Affidavit.pdf
PDF 83 KB Posted
- Attached to
- BACKFLOW PREVENTION EQUIPMENT AND INSTALLATION
- Solicitation number
- ARFQ-0512-WSH2500000005-2
- Issued by
- Lewis County, West Virginia
About this file
The document is a Drug Free Workplace Conformance Affidavit for the State of West Virginia, specifically addressing compliance with West Virginia Code §21-1D-5. This standardized form requires bidders on state contracts to attest that their company maintains a valid written drug-free workplace policy that complies with state regulations. The affidavit must be submitted with the bid, and failure to include it will result in automatic disqualification of the bid proposal.
The form is designed to ensure that companies seeking to do business with the State of West Virginia have established drug-free workplace policies, as mandated by state law. It requires an authorized company representative to swear under penalty of perjury that their organization has such a policy in place. The affidavit must be signed, dated, and notarized, with the notary public providing an official seal to validate the document. This requirement serves as a mechanism for the state to promote workplace safety and maintain professional standards among its contractors and vendors.
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| RFQ Specifications.docx | DOCX document | |
| BondLaborMat.pdf | ||
| OSAFederalFundsContractClauseAddendum.pdf | ||
| Bid Bond Instructions.pdf | ||
| Bid Bond Form.pdf | ||
| Final_ARFQ_0512_WSH2500000005_2_WV_ARFQ_FORM.PDF | ||
| WV36.pdf | ||
| WV72 Drug Free Coversheet.pdf | ||
| Addendum #1.pdf | ||
| EXHIBIT A.xlsx | XLSX spreadsheet | |
| Final_ARFQ_0512_WSH2500000005_1_WV_ARFQ_FORM.PDF | ||
| Purchasing Affidavit.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 .