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New Member Application Form

Contact Info

Personal / Home

First and Last Name*
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Middle Name*
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Email*
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Enter Email Again*
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Desired Password*
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Enter Password Again*
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Address*
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City*
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State*
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Zip / Postal Code*
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Home Phone*
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Cell Phone*
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Type in the Code*
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*
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Agency / Business

Organization*
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Address*
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City*
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State*
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Zip / Postal Code*
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Phone*
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Fax
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Send all mail to*

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Schooling and Training

Highest Attained Level of Education*

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List Colleges Attended / Fields of Study*
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Polygraph School

Name of School*
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Address*
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City*
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State*
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Zip*
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Phone*
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Dates of Attendance

Start Date
(mm/dd/yyyy)*
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End Date
(mm/dd/yyyy)*
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Dates of Issuance

Diploma
(mm/dd/yyyy)*
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Certification of Completion
(mm/dd/yyyy)*
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Please list names of two instructors who will endorse your application*
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Are you qualified to administer polygraph examinations in any language other than English?*
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If Yes, List all languages (separated by commas)
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Are you a member of any other state or national polygraph organization?*
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If Yes, list all organizations (separated by commas)
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Are you now or have you ever been licensed to conduct polygraph examinations by any other state or government agency?*
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If Yes, list all Agencies and License Numbers
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Questions

If you answer YES to any of the following questions, please render a full and detailed explanation in the provided textarea. Otherwise enter NO.

This information will be treated as confidential.

Have you ever had a polygraph license suspended or revoked?*
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Have you ever been convicted of any felony crime?*
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Have you ever been convicted / fined, in any court, of moral turpitude or amoral conduct?*
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Have you ever been a member of or associated with any group that advocates the violent overthrow of the United States Government?*
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Have you ever been expelled from or refused membership in any polygraph organization or any other organization or society?*
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Are you under indictment or investigation at present?*
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Have you ever been terminated or asked to resign from an employment for dishonesty or a serious violation of company policy?*
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Have you resigned or been dismissed from any State, Regional, National, or International association while under investigation, or for illegal or ethical reasons?*
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Endorsement

List one member of NPA or an individual who is a member of any other state or national polygraph association who will endorse you for membership

Name*
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Association*
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Address*
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City*
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State*
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Zip / Postal Code*
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Phone*
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You will immediately be taken to Paypal to pay your $100 application fee.

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