WPC  77WPC >?d~A?#@ ?:5 =C?K6D=Rz? +jz=w<,^oZ*7>  (  (Untitled)'3,, , ,   UB ) 3    *    d +    d ,    d /0ghjklmnopqrstuvwxyz{|}~P* * c:\inf42\forms\ad1049.wpf c:\inf41\phuong\ad1049.wpfUS&& &&   >3?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\ AD1049.DBFhistory   i)Address1  r   h ADDRESS1r i)Address2  r   h ADDRESS2r i)Address3  r   h ADDRESS3r i$Box      h BOX  i)OrgzName  I   h ORGZNAMEI i'AwdNum  I   h AWDNUMI i(NmTitle      h NMTITLE  i%Sign   I   h SIGN i%Date     h DATE ? @d @}?:~ ^ 2g U.S. DEPARTMENT OF AGRICULTURE F !"#                             P  &&    r  2 CERTIFICATION REGARDING  2 DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)  2C ALTERNATIVE I - FOR GRANTEES OTHER THAN INDIVIDUALS F !"#                             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 !"#                             P      h, & A.  !"#                             P  &    F, & The grantee certifies that it will or will continue to provide a drug-free workplace by:  3 !"#                             P  &    g\+ ,! & 1 7F !"#                             P  &&    ~,," & Form AD-1049 (REV 5/90) 09 !"#                             P  &    - ,# d This form was electronically produced by Elite Federal Forms Inc. %: !"#                             P  &      ^< 2 (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3) F !"#                             P  &&    yh,M & Alternative I  !"#                             P  &    iFV,N & (a)   !"#                             P  &    @V8RO & Publishing a statement notifying employees that the unlawful manufacture, distribution,  & dispensing, possession, or use of a controlled substance is prohibited in the grantee's  & workplace and specifying the actions that will be taken against employees for violation of  & such prohibition;  3 !"#                             P  &    iF,P & (b)   !"#                             P  &    @8,Q & Establishing an ongoing drug-free awareness program to inform employees about --  3 !"#                             P  &    i@^,R & (1)   !"#                             P  &    N ,S & The dangers of drug abuse in the workplace;  !"#                             P  &    i@d^,T & (2)    !"#                             P  &    d,U & The grantee's policy of maintaining a drug-free workplace;  $ !"#                             P  &    i@^,V & (3)  " !"#                             P  &    W & Any available drug counseling, rehabilitation, and employee assistance programs;  & and ". !"#                             P  &    i@^,X & (4)  % !"#                             P  &    Y & The penalties that may be imposed upon employees for drug abuse violations  & occurring in the workplace; %. !"#                             P  &    iF@,Z & (c)  ( !"#                             P  &    @@8[ & Making it a requirement that each employee to be engaged in the performance of the grant  & be given a copy of the statement required by paragraph (a):  (3 !"#                             P  &    iF!,\ & (d)  + !"#                             P  &    @!8] & Notifying the employee in the statement required by paragraph (a) that, as a condition of  & employment under the grant, the employee will --  +3 !"#                             P  &    i@#^,_ & (1)  - !"#                             P  &    #z ,` & Abide by the terms of the statement; and - !"#                             P  &    i@$^,a & (2)  / !"#                             P  &    7$b & Notify the employer in writing of his or her conviction for a violation of a criminal  & drug statute occurring in the workplace no later than five calendar days after such  & conviction; /. !"#                             P  &    iF',c & (e)  3 !"#                             P  &    @'8 d & Notifying the agency in writing, within ten calendar days after receiving notice under  & subparagraph (d)(2) from an employee or otherwise receiving actual notice of such  & conviction. Employers of convicted employees must provide notice, including position  33 !"#                             P  &    ?'=d =?K6g, ,6 & 2 9F !"#                             P  &&    }-` ,7 & Form AD-1049 (REV 5/90) 9: !"#                             P  &    i ^,g & (1)   !"#                             P  &    ~i & title, to every grant officer on whose grant activity the convicted employee was working, unless  & the Federal agency has designated a central point for the receipt of such notices. Notice shall  & include the identification number(s) of each affected grant; 7 !"#                             P  &    i,,j & (f)    !"#                             P  &    k & Taking one of the following actions, within 30 calendar days of receiving notice under  & subparagraph (d)(2), with respect to any employee who is so convicted --  7 !"#                             P  &    3 >l & Taking appropriate personnel action against such an employee, up to and including  & termination, consistent with the requirements of the Rehabilitation Act of 1973, as  & amended; or  1 !"#                             P  &    i ^,m & (2)  !"#                             P  &    [ >n & Requiring such employee to participate satisfactorily in a drug abuse assistance or  & rehabilitation program approved for such purposes by a Federal, State, or local health,  & law enforcement, or other appropriate agency; 1 !"#                             P  &    i,,p & (g)   !"#                             P  &    q & Making a good faith effort to continue to maintain a drug-free workplace through implementation  & of paragraphs (a), (b), (c), (d), (e) and (f). 7 !"#                             P  &    h\,r & B.  !"#                             P  &    \s & The grantee may insert in the space provided below the site(s) for the performance of work done in  & connection with the specific grant:  = !"#                             P  &    ,t & Place of Performance (Street address, city, county, State, zip code) ( !"#                             P  &     V  v      P    8D   Address1!"-x./567F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && = &      V  y      P    )x~, & if there are workplaces on file that are not identified here.   Box#z$% &%'-()+,-.                             P   !  * <  1  $ 2      3     k~X,{ & Check % !"#                             P  &&     W4! } Organization Name ,OrgzName!"-}./56*7&89:&;>?@ABCG                         P #      $      ' I  Y@$.,! *  < x&0 = x&     `|4! } Award Number or Project Name ,AwdNum!"-~./5-6*789:;>?@ABCG                         P #      $      ' I  Y@$.,! *  < &&0 = &&     p#  } Name and Title of Authorized Representative ,NmTitle!"-./56-7F89:F;>?@ABCG                         P #      $      '  I  Y@$.,! *  < x&0 = x&     K& } Signature ,Sign!"-./5617&89:&;>?@ABCG                         P #      $      '  I  Y@$.,! *  < x&0 = x&     H|& } Date ,Date! "-./5-61789:;>?@ABCG                         P #      $      ' I  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  "      #       88   Address2!"-./567F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && = &     8,   Address3!"-./56!7F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && = &     ?(=d =? +~ ^ 2 INSTRUCTIONS FOR CERTIFICATION F !"#                             P  &&    hr^ & 1.  !"#                             P  &    r^ & By signing and submitting this form, the grantee is providing the certification set out on pages 1 and 2.  C !"#                             P  &    h^ & 2.   !"#                             P  &    M & The certification set out on pages 1 and 2 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.   C !"#                             P      h ^ & 3.  !"#                             P  &     L & 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 identify 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      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      h^ & 6.  !"#                             P  &    b & 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      9L& & "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);  > !"#                             P      nL & "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;  "> !"#                             P       L & "Criminal drug statute" means a Federal or non-Federal criminal statute involving the manufacture, distribution,  & dispensing, use, or possession of any controlled substance;  &> !"#                             P      y: L & "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).  )> !"#                             P      g, , & 3 9F !"#                             P  &&    }-` , & Form AD-1049 (REV 5/90) 7: !"#                             P  &    ?n=d =<,defgh i <^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 ^=Z~4yZ