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Waiver and Release of Liability

A printed copy of the form shown below will be provided at the time of the Polygraph Examination.

I, ________________________________________, freely and voluntarily agree to be interviewed and to undergo polygraph examination(s) by employees of Clugston Polygraph & Investigative Services. I understand that I have the following rights:

  1. I may refuse to be interviewed or examined and, if so, I hereby authorize Clugston Polygraph & Investigative Services to inform ______________________________________ of my refusal.
     
  2. I may consult privately with a lawyer or with my parent(s) prior to the interview(s) and polygraph examination(s).
     
  3. The interview(s) and/or polygraph examination(s) will be terminated at any time I request and, if so, I hereby authorize Clugston Polygraph & Investigative Services to inform _______________________________ of my request.
     
  4. All questions to be asked in the polygraph examination(s) will be discussed with me prior to the actual testing.
     
  5. No questions pertaining to sexual subject-matter will be asked during the interview(s) and/or polygraph examination(s), unless such subject matter is relevant or necessary to conduct the investigation.
     
  6. I will not be asked any questions pertaining to religion or politics.
     
  7. I have the right to receive a copy of this “Waiver and Release of Liability” upon request.
     

I hereby authorize and request that employees of Clugston Polygraph & Investigative Services disclose to __________________________________ any and all information, conclusions, and opinions arising out of or connected with my interview(s) and polygraph examination(s), even though such information. conclusions, and opinions may be unfavorable or may result in adverse consequences to me.

I hereby release and forever discharge Clugston Polygraph & Investigative Services and ____________________________ their employees, agents, representatives, partners, officers, directors, and their successors from all liability, and from each and every demand, claim, or cause of action existing, or which may hereafter arise, resulting directly or indirectly from the conduct of my interview(s) and/or polygraph examination(s) and/or publication, communication or dissemination of any information, conclusions, and opinions arising out of or connected with my interview(s) and/or polygraph examination(s).

__________ Examinee Initials

 

Highest level of education completed: _______________________________________

I have carefully read this entire “Release and Waiver of Liability,” consisting of two (2) pages. I fully understand it.

By signing below, I acknowledge that I have reviewed and completed this “Waiver and Release of Liability” personally and with sufficient time to deliberate upon its contents.

My agreement to undergo interview(s) and polygraph examination(s) is given without threats, promises of leniency or immunity, reward or favoritism, duress, pressure or force. I believe my cooperation with Clugston Polygraph & Investigative Services is in my own best interest. I understand that Clugston Polygraph & Investigative Services is not acting as my agent, but rather Clugston Polygraph & Investigative Services is acting on behalf of _________________________________________.

 

________________________________________________         _____________________________
           Signature (Full Legal Name)                                                                 Date of Signature

 

________________________________________________        _____________________________
        Home Address                                                                                             Social Security Number

 

If you have a question or complaint, you may contact:

State of Oklahoma, Board of Polygraph Examiners
2401 Egypt Road
Ada, OK 74820-0669

 

________________________________________________
          Signature of Examiner

 

Clugston Polygraph and Investigative Services

 

 

 

Grove Office Location:
221 E 3rd St.
Grove, Oklahoma 74344

Mailing Address:
P.O. Box 452409
Grove, Oklahoma 74345-2409

Tulsa Office Location:
320 S Boston Ave.
Ste. 1130
Tulsa, Oklahoma 74103

Phone: 918-622-7008

 

e-mail: roy@clugston-investigations.com

Serving Northeast Oklahoma, as well as Tulsa and Oklahoma City

 

 

 

 

We comply fully with the Gramm-Leach-Bliley Act of 1999

 

 

 

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