Date:

I, _________________, hereby voluntarily give consent to a polygraph (lie detector) test to be administered on ________________, at ________________________________, the results of which will be forwarded to: _________________________________ for analysis.

I declare that I have not been coerced in any manner whatsoever to submit to this test or to sign this consent form and I understand that I have a legal right to refuse to submit to this test as a condition of new or continued employment.

_________________
Employee

_________________
Witness