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<br />DIVISION OF EMPLOYMENT SERVICES <br />PLACE OF PERFORMANCE <br />FOR CERTIFICATION REGARDING DRUG-FREE <br />,VORKPLACE REQUIREMENTS <br /> <br />Name: <br /> <br />Name of COtItractor: <br /> <br />Contractor Number: <br /> <br />Date: <br /> <br />The Contractor shall insert in the space provided below the site(s) expected to be used for <br />the performance of work under the contract covered by the certification: <br /> <br />Place ofPerfonnance (include street address, city, county, state, zip code for each site): <br /> <br />.._-....._____..-.:__'0;__""'.....-..___.......---... <br /> <br />--."""""""~~,..~_..",....~~~~___==__~,_,=_~___~~_:........".................~"'~,...._..T.,,~_.~ <br /> <br />---.".......................""""'~-..,.,......""""..~...-.,.,...........~-"..--~..,...._-----,-,-_...---~.,.,...,......-.,_....'.........--,..---"'._,-.-.....,..-.--,-,-".-.-, <br /> <br />__.~_~._.__._,_.___._._'____,_.._.....~A~_.~._.._,_.___...,_.__,...._.______~__~._,.__-...__""_____._._________"'___..._._.__,'____._.-~_....,..,,^---._- <br /> <br />25N-67 <br /> <br />