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DIVISION OF EMPLOYMENT SERVICES <br />PLACE OF PERFORMANCE <br />FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE <br />REQUIREMENTS <br />J ~ <br />Name: <br />Name of Contractor: <br />Contractor Number: <br />Date: ' Z ~ <br />The Contractor shall insert in the space proe idoedt act coveeedtby the pert f~ ation: <br />used for the performance of work under th <br />Place of Performance (include street address, city, county, state, zip code for each <br />site): <br />~1 <br /> <br />