I, (name of employee), have been advised by XYZ Employer that employers are generally prohibited from requesting or causing any applicant or employee to take a lie detector test.

Nonetheless, I, (name of employee), acknowledge that in the course of my employment, I requested that such a test be given to clear my name of the following serious alleged workplace impropriety: (specify).  As a prerequisite of such a test, I was given the opportunity to obtain and consult with legal counsel before each phase of the test; I was provided at least 48 hours' notice of the time and place of the test; I was advised beforehand of the nature and characteristics of the test and the instruments involved; I was provided an opportunity to review all questions to be asked at the examination; and I was given a copy of the results together with a copy of the federal Polygraph Protection Act of 1988.

I authorize that the results of any polygraph test be communicated and disclosed to third parties.  As a consequence of any negative result obtained from said test, I understand that I may be disciplined leading up to or including immediate discharge by XYZ Employer.

I hereby indemnify, release and forever discharge and hold XYZ Employer and its subsidiaries and affiliated companies, agents and employees harmless from any and all claims, demands, judgments and legal fees arising out of or in connection with such tests, the results, or any lawful use of the results.

______________________________________________

Signature of Employee

______________________________________________

Printed Name of Employee

Social Security Number:_____________________________

Date: ______________________________________________

Name of Witness: ________________________________________