Michael D. Park & Associates Polygraph

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PREPARED ON YOUR COMPANY LETTERHEAD

EMPLOYEE POLYGRAPH AGREEMENT

I have been served notice of a request to consent to a polygraph examination as evidenced in the attached notice. I, hereby consent to the test as requested, after being advised that I am not required to take the test as a condition of continued employment. I further understand that I may terminate the test at any point during the examination. I further attest that I am not under treatment by a physician or psychologist for any medical or psychological condition or undergoing any therapy that might cause an abnormal response during the test.

I understand that the results of the test will only be disclosed to a person that I designate in writing, to my employer, or a court, governmental agency, arbitrator or mediator pursuant to a court order. However, my employer may disclose any admissions of criminal conduct to the appropriate governmental agency. I further understand that the results of the test, with additional evidence, including any voluntary statements that I make, may be used by the employer in taking any employment related decisions, including decisions concerning my continued employment.

Prior to the examination I will be given the opportunity to review all questions that will be asked.

This polygraph examination is to be given pursuant to the Employee Polygraph Protection Act Of 1988 (the Act). Section 6 of the Act provides for civil penalties and injunctive actions by the Secretary of Labor. I may bring civil action within three (3) years of the polygraph test, if said test is requested or given in violation of the Act, this consent, or attached notice.

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Employee Signature                                                                               Date

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Company Representative Signature                                                        Date

Note: Fax Signed Forms to Michael D. Park & Associates Polygraph