NOTE TO APPLICANT: Thank you for your interest in becoming a member of this association. All sections of the application must be answered completely. If necessary use additional pages to provide the requested information. Any false statements are grounds for rejection. Please include a recent photograph of yourself, and copy of your basic polygraph school certificate (to be filed with your application). Print or type all answers.
CLASS OF MEMBERSHIP (check one):
( ) Full Membership ( ) Associate Membership ( ) Honorary Membership
APPLICANT INFORMATION:
Name: Last: _____________________ First: __________________ Middle Initial: _______
Date of Birth: ___________________ Place of Birth: ________________________________
Residential Address: ___________________________________________________________
Business Address: _____________________________________________________________
check mailing address preference: ( ) residence ( ) business
Website (optional): ____________________________________________________________
Residential Telephone (optional): _____________ Business Telephone: ____________
E-mail Address: ____________________________________________
MPA utilizes e-mail for preferred correspondence
LICENSE: List Polygraph license(s) you possess by state/number/date
- _____________________________________________________________________
- _____________________________________________________________________
- _____________________________________________________________________
POLYGRAPH TRAINING:
Basic Course: School: ____________________________________________________
Address: ________________________________________________________________
(include city/state/zip)
School Director: __________________________________________________________
Intern Supervisor: ___________________________
Graduation date: ____________________________
POLYGRAPH EXPERIENCE:
How many years have you been a polygraph examiner? _____
How many examinations have you conducted?_____
What percentage of your working time is devoted to polygraph work?_____
What other polygraph associations do you have membership status with?
Have you ever been denied a polygraph license?_____
Have you ever been denied membership to any polygraph association?_____
Have you ever been denied acceptance into a basic polygraph school?_____
(If you answered yes to questions 5,6, or 7 please provide complete details on a separate page.))
CHARACTER REFERENCES: (two must be polygraph examiners)
Name, Address (City/State/Zip), Email, Years known
- _________________________________________________________________
- _________________________________________________________________
- _________________________________________________________________
- _________________________________________________________________
PRESENT EMPLOYMENT:
Agency: _______________________________________________________
Address: ______________________________________________________
Name of contact person: _______________________________________
Telephone number: ____________________________________________
Email address:_________________________________________________
Dates of employment:___________________________________________
Are you presently employed as a Polygraphist? yes _____ no _____
Do you currently conduct polygraph examinations in private practice?
yes ____ no ____
PAST EMPLOYMENT:
If not presently employed as a Polygraphist, please provide most recent polygraph employment:
Agency:_______________________________________________________
Address:______________________________________________________
Name of contact person:__________________________________________
Telephone number: ______________________________________________
Email address:______________________________________________________
Dates of employment:_____________________________________________
PERSONAL BACKGROUND:
Have you ever been convicted of a felony or misdemeanor? _____
Have you ever been discharged or released under other than honorable conditions from any branch, department or agency of the federal, state, county or municipal government? _____
Have you ever been discharged or asked to resign from any employment, organizational membership of society? _____
(If you answered yes to any of the above questions, please provide complete details on a separate page.)
APPLICATION REQUEST:
I hereby apply for membership, pursuant to and subject to the Constitution, By-Laws, and Regulations of the Missouri Polygraph Association, by all of which I agree to be bound. I further agree to hold the Missouri Polygraph Association, its officers and agents, free from damage, liabilities or complaint, by reason of any action they, or any of them take in connection with this application. The information I have provided on this application is true and accurate to the best of my knowledge.
Signature: ____________________________________ Date: _______________
Dues/Fees:
Dues and fee of this association are established as follows:
Annual membership dues are $20.00; delinquent after Jan. 1st.
New members: $30.00 (includes $10.00 application fee) to be included with application and made payable to the Missouri Polygraph Association
Mail to:
Nathan S. Tretter, MPA Secretary
Lafayette County Sheriff's Department
107 South 11th Street
Lexington, MO 64067
MPA Official Use Only
1. Application received: Date: _________________
- Background completed: Date: _________________
- Background Investigator: ____________________________________________
2. Application approved: _____ Application rejected: _____ Date: _______________
3. Dates:
- membership certificate issued: ______________
- member nametag ordered: ______________
- constitution/by-laws issued: ______________
- member posted on website: ______________
