WPC  77WPC >?d~A?<@6?5N=`=? x==W^<(o^^o^Z`7>  (  (Untitled)'3,, , ,   UB ) 3    *    d +    d ,    d /0ghjklmnopqrstuvwxyz{|}~P* * c:\inf42\forms\ad1050.wpf c:\inf41\phuong\ad1050.wpfUS&& &&   >=?df eh Terminal 1 ! d !  d      Terminal eb Arial " ! 2     d    Arial ev Times New Roman  ! 2 F  d    Times New Roman ? Ad A{?<z jZ c:\inf41\forest\data\ AD1050.DBFhistory   i)OrgzName  A   h ORGZNAMEA i'AwdNum  A   h AWDNUMA i)NmsTitle      h NMSTITLE  i%Sign   A   h SIGN i&Sign2   A   h SIGN2 i%Date     h DATE ?d@d @}?5~ ^ 2 U.S. DEPARTMENT OF AGRICULTURE F !"#                             P  &&    r  2 CERTIFICATION REGARDING  2) DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)  2# ALTERNATIVE II - FOR GRANTEES WHO ARE INDIVIDUALS F !"#      Z                       P  &&    x  L  & This certification is required by the regulations implementing Sections 5151-5160 of the Drug-Free Workplace Act of 1988  & (Pub. L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR Part 3017, Subpart F, Section 3017.600, Purpose. The January  & 31, 1989, regulations were amended and published as Part II of the May 25, 1990 Federal Register (pages 21681-21691). Copies  & of the regulations may be obtained by contacting the Department of Agriculture agency offering the grant. F !"#      d                       P      i, & (a)  !"#                             P  &    UF & The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture,  & distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant.  ? !"#                             P  &    g, ,! & 1 9F !"#                             P  &&    ~j- ," & Form AD-1050 (REV 1/92) 4: !"#                             P  &    . ,# d This form was electronically produced by Elite Federal Forms Inc. -; !"#                             P  &      ^< 2 (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS BELOW) F !"#                             P  &&    zh,M & Alternative II  !"#                             P  &    i, & (b)  !"#                             P  &    UF & If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant  & activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to the grant  & officer or other designee, unless the Federal agency designates a central point for the receipt of such notices.  & When notice is made to such a central point, it shall include the identification number(s) of each affected grant.  ? !"#                             P  &    WX } Organization Name ^OrgzName!"-./56!7(89:(;>?@ABCG                         P #      $      ' A  Y@$.,! *  < x&0 = x&     `DX } Award Number or Project Name ^AwdNum!"-./5/6!789:;>?@ABCG                         P #      $      ' A  Y@$.,! *  < &&0 = &&     zL  } Name(s) and Title(s) of Authorized Representative(s) ^NmsTitle!"-./56%7F89:F;>?@ABCG                         P #      $      '  A  Y@$.,! *  < x&0 = x&     N! X } Signature(s) ^Sign!"-./56+789:;>?@ABCG                         P #      $      '  A  Y@$.,! *  < x&0 = x&     H! X } Date ^Date!"-./546+789:;>?@ABCG                         P #      $      ' A  Y@$.,! *  < &&0 = &&     2@HASVALUE (Date) and #UPDATONLY    Date  ~      7@datevalue (@datetext (Date, "%2-%1-%5"))   Date   %2-%1-%5  "  #  4@VALUE (@DATETEXT (Date,"%5"))<=29   Date   %5  "  x         p@SETVALUE (Date, @DATEVALUE (@CONCAT (@DATETEXT (Date,"%2-%1"),"-20",@DATETEXT (Date,"%5"))),TRUE)   Date   Date   %2-%1  "   -20   Date   %5  "      #       $ ^ 2 INSTRUCTIONS FOR CERTIFICATION /F !"#                             P  &&    h&, & 1. 1 !"#                             P  &    &, & By signing and submitting this form, the grantee is providing the certification set out on page 1.  19 !"#                             P  &    h (, & 2. 3 !"#                             P  &    F (F & The certification set out on page 1 is a material representation of fact upon which reliance is placed when the  & agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or  & otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies  & available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.  3@ !"#                             P  &    5! X ^Sign2!"-./56+789:;>?@ABCG                         P #      $      '  A  Y@$.,! *  < x&0 = x&     ?=d =? h~^ & 3.  !"#                             P  &    ~ & Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they  & may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or  & upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make  & the information available for Federal Inspection. Failure to identify all known workplaces constitutes a violation of the  & grantee's drug-free workplace requirements.  C !"#                             P      g, , & 2 9F !"#                             P  &&    }-` , & Form AD-1050 (REV 1/92) 9: !"#                             P  &    h. ^ & 4.   !"#                             P  &     .  & Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work  & under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State  & highway department while in operation, State employees in each local unemployment office, performers in concert halls  & or radio studios).   C !"#                             P      h ^ & 5.  !"#                             P  &    N & & If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the  & agency of the change(s), if it previously identified the workplaces in question (see paragraph three).  C !"#                             P      hn^ & 6.  !"#                             P  &    cn & Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common  & rule apply to this certification. Grantees' attention is called, in particular, to the following, definitions from these rules:  C !"#                             P      8\& & "Controlled substance" means a controlled substance in Schedules I through V of the Controlled Substances Act (21  & U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);  C !"#                             P      `& & "Conviction" means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any  & judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;  C !"#                             P        & & "Criminal drug statute" means a Federal or non-Federal criminal statute involving the manufacture, distribution,  & dispensing, use, or possession of any controlled substance;  C !"#                             P      jdx & "Employee" means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) all  & "direct charge" employees; (ii) all "indirect charge" employees unless their impact or involvement is insignificant to the  & performance of the grant; and (iii) temporary personnel and consultants who are directly engaged in the performance of  & work under the grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of  & the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on  & the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces).   C !"#                             P      ?)=d =<(defgh <@^o elite10.DLL IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. elite10.COM IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. WPIN$ELITE10FunctionSet,4.1 ^=Zp߳ZO