Form STD.21 "Drug-Free Workplace Certification" - California

What Is Form STD.21?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form STD.21 by clicking the link below or browse more documents and templates provided by the California Department of General Services.

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Download Form STD.21 "Drug-Free Workplace Certification" - California

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STATE OF CALIFORNIA
DRUG-FREE WORKPLACE CERTIFICATION
STD. 21 (Rev. 10/2019)
CERTIFICATION
I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or
grant recipient to the certification described below. I am fully aware that this certification, executed
on the date below, is made under penalty of perjury under the laws of the State of California.
CONTRACTOR/BIDDER FIRM NAME
FEDERAL ID NUMBER
BY (Authorized Signature)
DATE EXECUTED
PRINTED NAME AND TITLE OF PERSON SIGNING
TELEPHONE NUMBER (Include Area Code)
(
)
TITLE
CONTRACTOR/BIDDER FIRM'S MAILING ADDRESS
The contractor or grant recipient named above hereby certifies compliance with Government Code Section 8355
in matters relating to providing a drug-free workplace. The above named contractor or grant recipient will:
1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession,
or use of a controlled substance is prohibited and specifying actions to be taken against employees for
violations, as required by Government Code Section 8355(a).
2. Establish a Drug-Free Awareness Program as required by Government Code Section 8355(b), to inform
employees about all of the following:
(a) The dangers of drug abuse in the workplace,
(b) The person's or organization's policy of maintaining a drug-free workplace,
(c) Any available counseling, rehabilitation and employee assistance programs, and
(d) Penalties that may be imposed upon employees for drug abuse violations.
3. Provide as required by Government Code Section 8355(c), that every employee who works on the proposed
contract or grant:
(a) Will receive a copy of the company's drug-free workplace policy statement, and
(b) Will agree to abide by the terms of the company's statement as a condition of employment on
the contract or grant.
4.
At the election of the contractor or grantee, from and after the "Date Executed" and until
(
)
DATE
(NOT TO EXCEED 36 MONTHS), the state will regard this certificate as valid for all contracts or grants
entered into between the contractor or grantee and this state agency without requiring the contractor or
grantee to provide a new and individual certificate for each contract or grant. If the contractor or grantee
elects to fill in the blank date, then the terms and conditions of this certificate shall have the same force,
meaning, effect and enforceability as if a certificate were separately, specifically, and individually provided
for each contract or grant between the contractor or grantee and this state agency.
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Print
STATE OF CALIFORNIA
DRUG-FREE WORKPLACE CERTIFICATION
STD. 21 (Rev. 10/2019)
CERTIFICATION
I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or
grant recipient to the certification described below. I am fully aware that this certification, executed
on the date below, is made under penalty of perjury under the laws of the State of California.
CONTRACTOR/BIDDER FIRM NAME
FEDERAL ID NUMBER
BY (Authorized Signature)
DATE EXECUTED
PRINTED NAME AND TITLE OF PERSON SIGNING
TELEPHONE NUMBER (Include Area Code)
(
)
TITLE
CONTRACTOR/BIDDER FIRM'S MAILING ADDRESS
The contractor or grant recipient named above hereby certifies compliance with Government Code Section 8355
in matters relating to providing a drug-free workplace. The above named contractor or grant recipient will:
1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession,
or use of a controlled substance is prohibited and specifying actions to be taken against employees for
violations, as required by Government Code Section 8355(a).
2. Establish a Drug-Free Awareness Program as required by Government Code Section 8355(b), to inform
employees about all of the following:
(a) The dangers of drug abuse in the workplace,
(b) The person's or organization's policy of maintaining a drug-free workplace,
(c) Any available counseling, rehabilitation and employee assistance programs, and
(d) Penalties that may be imposed upon employees for drug abuse violations.
3. Provide as required by Government Code Section 8355(c), that every employee who works on the proposed
contract or grant:
(a) Will receive a copy of the company's drug-free workplace policy statement, and
(b) Will agree to abide by the terms of the company's statement as a condition of employment on
the contract or grant.
4.
At the election of the contractor or grantee, from and after the "Date Executed" and until
(
)
DATE
(NOT TO EXCEED 36 MONTHS), the state will regard this certificate as valid for all contracts or grants
entered into between the contractor or grantee and this state agency without requiring the contractor or
grantee to provide a new and individual certificate for each contract or grant. If the contractor or grantee
elects to fill in the blank date, then the terms and conditions of this certificate shall have the same force,
meaning, effect and enforceability as if a certificate were separately, specifically, and individually provided
for each contract or grant between the contractor or grantee and this state agency.