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Q <br /> " 21 <br /> CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS <br /> I1.The site(s)for the performance of work done in connection with the specific agreement are listed below: <br /> 1. <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 for 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,or government-wide Federal suspension or debarment(Section 4 CFR Part 85, <br /> Section 85.615 and 86.620). <br /> EXECUTED BY <br /> CONTRACTOR AUTHORIZED OFFICER <br /> ADDRESS DATE <br /> (Certification signature should be same as Contract signature.) <br />