State of West Virginia
DRUG FREE WORKPLACE CONFORMANCE AFFIDAVIT
West Virginia Code §21-1D-5
STATE OF ________________________
COUNTY OF _______________, TO-WIT:
I, _______________________, after being first duly sworn, depose and
state as follows:
I am an employee of _________________________________; and,
I do hereby attest that ____________________________________
maintains a valid written drug free workplace policy and that such
policy is in compliance with West Virginia Code §21-1D-5.
The above statements are sworn to under the penalty of perjury.
Taken, subscribed and sworn to before me this _____ day of ____________.
By Commission expires _________________________
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
Rev March 2009