Miss. Code. tit. 18, pt. 21, ch. 1, r. 18-21-1-21.1, CERTIFICATION FORM DRUG-FREE WORKPLACE

Current through December 10, 2024

CERTIFICATION FORM DRUG-FREE WORKPLACE

CERTIFICATIONS FORM FOR DRUG-FREE WORKPLACE

The sub grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific sub grant. Check X if there are workplaces on file that are not identified here:

Place of Performance (street address, city, county, state, zip code)

750 North State Street

Jackson, MS 39202Hinds County

DRUG-FREE WORKPLACE (SUBGRANTEES WHO ARE INDIVIDUALS)

As required by the Drug-Free Workplace Act of 1988 -

A. As a condition of the sub grant. I certify that I will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the sub grant; and,

B. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any sub grant activity, I will report the conviction, in writing, within 10 calendar days of the conviction, to MDHS.

As duly authorized representative of the sub grantee, I hereby certify that the sub grantee will comply with the above certifications.

SUBGRANTEE NAME AND ADDRESS:

Mississippi Department of Human Services

750 North State Street, Jackson, MS 39202

TYPED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:

Leigh Washington, Director, Office of Social Services Block Grant

Click Here To View Image

Miss. Code. tit. 18, pt. 21, ch. 1, r. 18-21-1-21.1, CERTIFICATION FORM DRUG-FREE WORKPLACE

Adopted 10/1/2015