Form 40-0895-8 - Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals - Department Of Veterans Affairs Page 2

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OMB NUMBER: 2900-0559
Respondent Burden: 15 minutes
CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
INSTRUCTION: The grantee shall insert in the space provided below the site(s) for performance of work done in connection with
the specific grant (street address, city, county, state, zip code).
STREET ADDRESS
CITY
COUNTY
STATE
ZIP CODE
REMARKS
NAME OF ORGANIZATION
PROJECT FAI (Federal Application Identifier) NO.
TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE
NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE
SIGNATURE
DATE (mm/dd/yyyy)
VA FORM
40-0895-8
PAGE 2 OF 2
OCT 2010

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