This is a document that a company can use to obtain the consent of employees to
undergo a lie detector test. This document notifies the employees that they are not
legally obligated to take the test and that they are voluntarily submitting their approval
and consent. Additionally, this document requires the presence and signature of a
witness. This consent form can be used by small businesses or other entities that wish
to obtain consent from an employee to undergo a lie detector test.
CONSENT TO LIE DETECTOR TEST
Date: ___________, 201___[PROVIDE DATE THIS FORM IS SIGNED]
I, _____________________, hereby voluntarily agree and give my free consent to a polygraph
test to be administered on _________________, 201___, at __________________.[PROVIDE
NAME AND ADDRESS OF PLACE WHERE TEST WILL BE PERFORMED] The results
of this test shall be forwarded to _______________________
___________________________________ [PROVIDE NAME AND ADDRESS OF
AGENCY/BUSINESS/ORGANIZATION THAT WILL RECEIVE THE TEST RESULTS]
I understand and declare the following:
(1) I have a legal right not to take this test as a condition of employment or continued
(2) I am voluntarily submitting myself to this test. I have not been coerced in any manner
whatsoever to take this test or to sign this consent form. .
(3) I have retained a copy of this form for my records.
Print Name and Signature of Witness: __________________________________________
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