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DIVISION OF EMPLOYMENT SERVICES <br /> PLACE OF PERFORMANCE <br /> FOR CERTIFICATION REGARDING DRUG-FREE <br /> WORKPLACE REQUIREMENTS <br /> Name: <br /> Name of Contractor: <br /> Contractor Number: <br /> Date: <br /> <br /> The Contractor shall insert in the space provided below the site(s) expected to be used <br /> <br /> for the performance of work under the contract covered by the certification: <br /> Place of Performance (include street address, city, county, state, zip code for each site): <br /> EXHIBIT C <br /> 25B-21 <br /> <br />