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(1) Abide by the terms of the statement; and
<br />(2) Notify the employer in writing of his or her conviction for a
<br />violation of a criminal drug statute occurring in the workplace
<br />no later than five calendar days after such conviction;
<br />NNotifying, the agency, in writing, within 10 Calendar days
<br />er receiving novice under subparagraph (d1(2) from an
<br />Check
<br />employee or otherwise receiving actual notice c such convic-
<br />tion.
<br />here.
<br />Employers of convicted employees must provide notice
<br />including position title to: Department of Justice, Office of
<br />Section 67,
<br />Justice Programs, ATtN: Control Desk, 633 Indiana Avenue,
<br />is a State
<br />N.W., Washington D.C. 20531. Notice shall include the loan-
<br />frf!cation number(sj of each affected grant;
<br />fiscal year.
<br />plication for
<br />(f) Taking one of the following actions, within 30 calendar
<br />agencies in
<br />days of receiving notice under subparagraph (d)(2), with
<br />Check
<br />respect to any employee who is so convicted-
<br />4061/7.
<br />if there are workplace on file that are not identified
<br />630 of the regulations provides, that a grantee that
<br />may elect to make one certification in each Federal
<br />A copy of which should be included with each ap-
<br />DePartment of Justice funding. States and State
<br />ay elect to use OJP Form 4061/7.
<br />if the State has elected to complete OJP Form
<br />(1) Taking apppropriate personnel action against such an
<br />employee, up to and including termination, consistent with the DRUG -FREE WORKPLACE
<br />requirements of the Rehabilitation Act of 1973, as amended; or (GRANTEES WHO ARE INDIVIDUALS)
<br />(2) Requiring such employee to ,participate satisfactorily in a As required by the Drug Free Workplace Act of 1968, and
<br />drug ahuse assistance or rehabilitation program approved for implemented at 28 CFR Part 67, Subppart F, for ggrantees, as
<br />such purposes by a Federal, State, or local health, law enforce- defined at 28 CFR Part 67; Sections 67.615 and 67.620-
<br />ment, or other appropriate agency;
<br />( A. As a condition of the grant I certify that I will not en age
<br />freeMworkglace throughh implementation of paragraphs (a), (bl,
<br />(c), (d), (e�, and (f).
<br />B. The grantee may insert in the space provided below the
<br />site(s) for the performance of work done in connection with
<br />the specific grant:
<br />Place of Performance (Street address, city, country, state, zip
<br />code)
<br />in the unlawful manufacture distribution, dispensing, posses-
<br />sion, or use of a controlled substance in condition any
<br />activity with the grant; and
<br />B. If convinced of a criminal drug offense resulting from a
<br />violation occurring during the conduct of any grant activity, I
<br />will report theconviction, in writing, within y0 calendar days
<br />of the conviction, to: Department of Justce, Office of Justice
<br />Programs, ATTN: Control Desk, 633 Indiana Avenue, N.W.,
<br />Washington, D.C. 20531.
<br />As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.
<br />1. Grantee Name and Address:
<br />Santa Ana Police Department
<br />2. Application Number and/or Project Name
<br />4. Typed Name and Title of Authorized Representative
<br />David Valentin, Chief of Police
<br />3. Grantee IRS/Vendor Number
<br />
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