POLYGRAPH RELEASE AND CONSENT FORM
I, _______________________________________ do hereby voluntarily, without duress, coercion, promise of reward or immunity, agree to allow ____________________ to submit to a polygraph examination, having said technique explained to my satisfaction. I hereby release and forever discharge LaCosta Data Services and any and all of its officers, agents, employees and associates of and from any and all causes of action, claims, or legal actions which I have now or may ever have resulting directly or indirectly from my allowing __________________ to take this examination, and from the opinions expressed by the polygraph examiner and do further authorize the release of the results of said examination, and the information obtained to those parties having an interest in same. To the best of my knowledge, at this time, ________________has no physical or mental condition which would prevent her/her from taking this examination.
Signature of Person Being Examined (Guardian) Date
The examination now being over, I certify that I took this polygraph examination voluntarily, was well-treated and remained of my own freewill, having been advised that I could leave at any time. I was not asked any questions which I consider personal or private in nature.
Signature of Person Being Examined Dianne Decker Robinson
WRITTEN QUTHORIZATION TO INSPECT POLYGRAPH RECORDS
TEXAS STATE BOARD REGULATION 395.17 EFFECTIVE 5/15/92
I, ____________________________________________ , (do/do not) hereby authorize Dianne Decker Robinson, Polygraph Examiner, to release all information obtained during this polygraph examination to the Texas Polygraph Examiners Board or its employees for the purpose of routine compliance inspection. I understand that the inspection, if performed, would be to ascertain that this polygraph examination was administered in compliance with the Texas Polygraph Examiners Act and the Boards rules and regulations. I understand that the Polygraph Examiners Board and its employees shall keep this information confidential as required by law. I also understand that I am not required by any law to release this information.
Signature of Person Being Examined (Guardian)
Texas Polygraph Examiners Board
P.O. Box 4087 Austin, TX, 78773-0001 (512) 465-2058
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