Polygraph Consent

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

DATE: {{date}}

SUBJECT: Consent to Undergo Polygraph Examination

I, {{employee_name}}, ID/Passport Number {{id_number}}, hereby acknowledge that I have been requested by {{company_name}} (the “Company”) to undergo a polygraph examination in connection with {{reason_for_examination}}.

Voluntary and Informed Consent

I understand that my participation in this polygraph examination is entirely voluntary and that I have the right to refuse to participate without prejudice to my employment.

I confirm that I am not acting under any duress or undue influence and that I am providing my consent freely and willingly.

I have been informed of the nature of the polygraph examination, including the types of questions that may be asked, and the general procedure involved.

Purpose of the Examination

I understand that the primary purpose of this examination is to assist the Company in {{stated_purpose_of_examination}}.

I acknowledge that this examination is not intended as the sole basis for any disciplinary action, but rather as one tool among others to gather information.

Confidentiality and Disclosure

I understand that the results of this polygraph examination will be treated with confidentiality and will only be disclosed to authorized personnel within {{company_name}} involved in the investigation or decision-making process.

I further understand that the results may be used in accordance with the Company’s policies and relevant labor laws.

My Rights

I have been informed of my right to consult with a legal representative or a trade union representative prior to consenting to and undergoing the polygraph examination.

I understand that I have the right to terminate the examination at any point should I feel unwell or uncomfortable, without penalty.

Declaration

By signing below, I confirm that I have read and understood the terms of this consent form and that I voluntarily agree to undergo the polygraph examination.

Signature Block

_____________________________

Employee Name: {{employee_name}}

Date: {{date}}

_____________________________

Witness Name: {{witness_name}}

Date: {{date}}

For {{company_name}}:

_____________________________

Authorized Company Representative: {{company_representative_name}}

Date: {{date}}