STATE OF WEST VIRGINIA Commissioner of Labor POLYGRAPH EXAMINER'S APPLICATION I hereby make application for ( ) an original polygraph license, ( ) a renewal of my polygraph license, or ( ) registration as a polygraph intern. 1 NAME IN FULL (Last) (First) (Middle) 2 SOCIAL SECURITY NUMBER xxx - xx - 3 STREET ADDRESS CITY STATE ZIP CODE COUNTY PHONE 4 BUSINESS ADDRESS CITY STATE ZIP CODE COUNTY PHONE 5 NAME OF FIRM OWNER(S) TYPE OF BUSINESS ( ) Police ( ) Military ( ) Drug ( ) Other If other, specify 6 DATE OF BIRTH PLACE OF BIRTH a. Are you a citizen of the United States? ( ) Yes ( ) No b. If foreign born, give date and place of naturalization. 7 In what other states do you hold a license? a. Have you ever been refused a license? ( ) Yes ( ) No b. Have you ever been sued as a result of an examination? ( ) Yes ( ) No If you answered yes to either (a) or (b), give full details on a separate sheet. 8 Approximate number of examinations that you have given 9 Military Service Information: Branch Dates of Service: From to Military Serial Number: Rank Type of Discharge: 10 Have you ever been arrested? ( ) Yes ( ) No If Yes, give full details on separate sheet. 11 Name and address of high school or college from which you graduated or obtained a degree: Date of Graduation Type of Degree 12 Name and address of polygraph training school Dates attended: to 13 Employment experience relating to polygraph examinations for the past 5 years. Business Name & Dates of Reason for Position Held Address Employment Leaving 14 Give three personal references (not including relatives or fellow employees) who are householders or property owners, business or professional persons who have known you well during the past five (5) years. # Years Job Description/ Name Home Address Known Name of Employer Signature of Applicant Attach a recent Taken, subscribed and sworn to before me by the full face photograph above-named applicant this day of , 20 . Notary Signature not larger than My commission expires 3 X 4 inches The Division of Labor processes your personal information for appropriate and customary business purposes. Your personal information may be disclosed to other State agencies or third parties in the normal course of business as needed to comply with State and Federal Laws. If you have any questions about the Division of Labor's use of your personal information or would like a copy of the Division's complete privacy notice, please contact the Webmaster, Robert Bryant at Robert.L.Bryant@wv.gov or the Division's Privacy Officer, John Junkins at John.R.Junkins@wv.gov.