VIRGINIA POLYGRAPH
ASSOCIATION
P.O. Box 6311A 23188
NAME:
Home Address:
City,State, Zip:
HOME PHONE:
EMAIL:
Primarily employed as:
Law Enforcement
Private
Government
Current Employer (Name & Address):
Date of Employment:
Business Phone:
Former Employer (if less than 1
yr. with current employer)
Period of Employment
Business Phone:
Polygraph Training (include all school and preceptor training and dates attended.)
Education (include date degree or diploma received.)
References (List three references to include at least one VPA member.)
Name
Name
Memberships (Polygraph associations and other
professional organizations.):
Polygraph License( s)
Held and Date Licensed:
Type of Membership Requested:
Member *Associate
T his application
is complete and correct to the best of my knowledge. I agree to abide by the bylaws and
provisions of the Constitution as adopted by the members of the Virginia Polygraph
Association. If I am accepted as a member of the VPA, I further agree that I will not make
any public statement or utterance purporting to represent the VPA or regarding any other
examinees professional ability, honesty or integrity. Any derogatory comments I have
concerning any other examiner will be submitted in writing to the governing body of this
organization.I hereby release the Virginia Polygraph Association, its officers, members or agents,
from all legal claims of liability for any damages, either directly, or indirectly,
resulting from or arising out of any investigation regarding this application.
SIGN:
BY
TYPING YOUR NAME IN THE BOX, YOU AGREE TO THE ABOVE STATEMENTS ON THIS
FORM. Please
send
your check for $50 to cover yearly dues to the name and
address reflected on the top of the form.
