Va Form 10-0388-8 - Certification Regarding Drug-Free Workplace Requirements For Grantees Other Than Individuals Page 2

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CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
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
ORGANIZATION NAME
GRANT NUMBER OR NAME
NAME OF AUTHORIZED REPRESENTATIVE
TITLE OF AUTHORIZED REPRESENTATIVE
(mm/dd/yyyy)
SIGNATURE
DATE
VA FORM
10-0388-8
PAGE 2 OF 2
MAR 2005

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