Membership Application Page | The Arizona Polygraph Association

- Step 1 of 9

CLASS OF MEMBERSHIP DESIRED: *

Intern
Associate
Member

PERSONAL INFORMATION

Last Name *

First Name *

Middle Name

Date of Birth *

Place of Birth

MAILING ADDRESS

Address

City

State

Zip

CURRENT BUSINESS/EMPLOYER’S NAME

CURRENT BUSINESS/EMPLOYER’S ADDRESS

Address

City

State

Zip

PRESENT OCCUPATION/JOB TITLE:

CONTACT INFORMATION

Home

Work

Cell

Primary Email *

Secondary Email

Where would you like AzPA correspondence mailed? *

Residence
Business/Employer

AMOUNT OF TIME DEVOTED TO POLYGRAPH WORK

Days per week?

Hours per Day?

EDUCATION

Name and Address of School Attended. Did you graduate? Type of Degree obtained

POLYGRAPH TRAINING

What is the name of the polygraph school you attended?

What is the address of the polygraph school you attended?

What were your basic examiner school dates of attendance?

How many hours of instruction did you complete during your basic examiner course?

What was the name of the primary instructor during your basic examiner course?

How many polygraph examinations did you complete during your basic examiner course?

What polygraph equipment do you currently use or have you previously used?

How many continuing education hours have you completed in the last year? Three years?

POLYGRAPH EXPERIENCE (If more than 3, please use the Continuation page.)

Name of employer

Address

Dates of employment

Name of position held

Total number pre-employment or screening exams completed in last 3 years

Total number of other exams completed in the last 3 years

Total number pre-employment or screening exams completed in last 3 years (copy)

Name of employer

Address

Dates of employment

Name of position held

Total number pre-employment or screening exams completed in last 3 years

Total number of other exams completed in the last 3 years

Name of employer

Address

Dates of employment

Name of position held

Total number pre-employment or screening exams completed in last 3 years

Total number of other exams completed in the last 3 years

OTHER POLYGRAPH LICENSES

State

Number

Dates held

OTHER PROFESSIONAL ORGANIZATIONAL MEMBERSHIPS

Organization name

From when to when?

MILITARY SERVICE

Branch

Dates of Service

Discharge Type

Please answer the following question truthfully and completely. If additional space is needed, please utilize the Continuation Page at the end of this application.

A. Have you ever been investigated or charged with a criminal offense? ( ) Yes ( ) No If yes, please explain below.

B. Have you ever been refused a bond? ( ) Yes ( ) No ( ) N/A If yes, please explain below.

C. Have you ever been discharged from any employment? ( ) Yes ( ) No If yes, please explain below.

D. Have you ever been expelled from membership in any organization or society? ( ) Yes ( ) No If yes, please explain below.

E. Have you now or have you ever been a member of a subversive organization? ( ) Yes ( ) No If yes, please explain below.

F. Have you ever been denied/refused/revoked a professional membership of any organization? ( ) Yes ( ) No If yes, please explain below.

G. Have you been fired for cause from a government agency? ( ) Yes ( ) No If yes, please explain below.

REFERENCES (Please include names and addresses for 4 personal/professional references.

I understand that I will not receive, and I am not entitled to information collected during the course of my application process, and I further understand the information collected will be used in the evaluation process for my membership with the Arizona Polygraph Association (AzPA). I affirm that I have completed this application on my own and for myself and information provided is truthful and honest. I agree to hold said Arizona Polygraph Association, its members, examiners, officers, and agents free from damage, liabilities or complaint, by reason of any action they, or any of them, take in connection with this application.

I will be notified upon a successful preliminary review of my application and will provide sample polygraph charts for evaluation by the AzPA membership committee at which time I will also provide a $75.00 membership application fee via check or money order made payable to the AzPA.

Applicant Signature *

Date *

Subscribed and sworn to before me this ( ) day *

of *

201.. *

My commission expires

Notary Public Signature and Seal

THIS APPLICATION IS NOT A GUARANTEE OF MEMBERHIP. ADDITIONALLY, THE APPLICANT MUST BE PRESENT AT AN AZPA MEETING/CONFERENCE IN ORDER TO BE VOTED INTO MEMBERSHIP. IF THE APPLICANT IS NOT AVAILABLE THEN THE VOTE FOR MEMBERSHIP WILL BE TABLED UNTIL THE APPLICANT IS PRESENT.

CONTINUATION PAGE

Comment