Request for Polygraph Test...


SAMPLE AGREEMENT TO CONDUCT A POLYGRAPH EXAMINATION


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NOTICE OF POLYGRAPH TEST

TO: NAME OF EMPLOYEE
      ADDRESS
      ADDRESS

[Date]

Address to:
Michael D. Park & Associates
Dallas Polygraph Services
9330 LBJ (635) Freeway, Suite 900
Dallas, Texas 75243

SUBJECT: Notice of Polygraph Examination In Compliance With the Polygraph Protection Act of 1988 As Amended Concerning Our Employee [Name of Employee - Social Security Number] Dear [Mr. Park]:

You are requested to administer a polygraph examination on the above referenced employee. I have read the reference relevant paragraphs in title 29, Sub-title B, Chapter V, Part 801. We believe that we are in compliance with the regulations as prescribed by the Labor Department.

We have issued the 48-hour notice to the identified employee who has been instructed to report to your office at the appointed time. It is our understanding that you will provide our employee instructions as required under the regulation.

A statement of the case facts is attached along with the payment for the examination fee. We understand the first $100.00 of this fee is a non-refundable retainer to block the scheduled appointment time only. We expect that you will provide to us a written report concerning the results of the pretest interview, polygraph examination results and the posttest review.



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