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CONSENT FOR VOLUNTARY POLYGRAPH TESTING

Current Date

Date of Polygraph Examination: Exam Date. Polygraph Administered By signator, authorized signature or signer. You must be at least 18 years of age to agree to this consent form.

If you are not at least 18 years of age, you must additionally get a parent or guardian to sign this form in the space provided below. I understand the reason for this polygraph test and do hereby freely give my consent to have this test taken. I also understand that the results of this test shall be made available to Company Name and become part of my permanent record with Company Name. I further attest that I have not been coerced or pressured into taking this test or signing this form.

I understand that I have the right not to undertake this examination as a condition of employment or continued employment with Company Name. I hereby authorize any Company-approved vendor or agent to conduct such testing and to provide the results to Company Name. I understand that by signing this consent form, I hereby release Company Name and any person affiliated with Company Name from any liability arising out of the testing procedure, the results of such testing, or any other liability or damages, whether direct or indirect, from undergoing this Polygraph Testing.

I hereby authorize these test results to be released to Company Name.

Print Name:

Date when the contact was signed

Parent or Guardian Signature:

Human Resources Department