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CERTffICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Page 2 °~ 4 <br />II. The site(s) for the performance of work done in connection with the specific agreement are listed below: <br />I. <br />(Street address) <br />(City, county, state, zip code) <br />2. <br />(Street address) <br />(City, county, state, iip 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 granu, or government-wide Federal suspension or debarment (Section 4 CFR Part 85, <br />Section 85.615 and 86.620). <br />EXECUTED BY <br />CONTRACTOR <br />ADDRESS <br />AUTHORIZED OFFICER <br />DATE <br />(Certification signature should be same az Contract signature.) <br />