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CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Page 2 <br />II. The site(s) for the performance of work done in connection with the specific agreement are listed below: <br />(Street address) <br />(City, county, state, zip code) <br />2. <br />(Street address) <br />(City, county, state, zip code) <br />Contractor will inform the Department of any additional sites far performance of work under this <br />agreement. <br />False certification or violation of the certification shall be grounds for suspension of payment, suspension <br />or termination of grants, ar government-wide Federal suspension or debarment (Section 4 CFR Part 85, <br />Section 85.615 and $b.6x0). <br />EXECUTED BY <br />CONTRACTOR AUTHORIZED OFFICER <br />ADDRESS <br />(Certification signature should be same as Contract signature.) <br />DATE <br />,:~ <br />