I, _______________________________________, freely and voluntarily agree to be interviewed and to undergo polygraph examination(s) by employees of Empire Pacific Investigative Services.  I understand that I have the following rights:                  

1)    I may refuse to be interviewed or examined and, if so, I hereby authorize Empire Pacific Investigative Services to inform ______________________________ of my refusal.

2)    I may consult privately with a lawyer or with my parent(s) prior to the interview(s) and polygraph examination(s).

3)    The interview(s) and/or polygraph examination(s) will be terminated at any time I request and, if so, I hereby authorize Empire Pacific Investigative Services to inform ______________________________ of my request.

4)    All questions to be asked in the polygraph examination(s) will be discussed with me prior to actual testing.

5)    No questions pertaining to sexual subject-matter will be asked during the interview(s) and/or polygraph examination(s), unless such subject matter is relevant or necessary to conduct the investigation.

6)    I will not be asked any questions pertaining to religion or politics.

7)    I have the right to receive a copy of this "Waiver and Release of Liability" upon request. 

I hereby authorize and request that employees of Empire Pacific Investigative Services disclose to ______________________________ any and all information, conclusions, and opinions arising out of or connected with my interview(s) and polygraph examination(s), even though such information, conclusions, and opinions may be unfavorable or may result in adverse consequences to me. 

I hereby release and forever discharge Empire Pacific Investigative Services and ______________________________ their employees, agents, representatives, partners, officers, directors, and their successors from all liability, and from each and every demand, claim, or cause of action existing, or which may hereafter arise, resulting directly or indirectly from the conduct of my interview(s) and/or polygraph examination(s) and/or publication, communication or dissemination of any information, conclusions, and opinions arising out of or connected with my interview(s) and/or polygraph examination(s).

Highest level of education completed, ______________________________.

I have carefully read this entire "Release and Waiver of Liability," consisting of two (2) pages. I fully understand it.

By signing below, I acknowledge that I have reviewed and completed this "Waiver and Release of Liability" personally and with sufficient time to deliberate upon its contents.

My agreement to undergo interview(s) and polygraph examination(s) is given without threats, promises of leniency or immunity, reward or favoritism, duress, pressure or force. I believe my cooperation with Empire Pacific Investigative Services is in my own best interest. I understand that Empire Pacific Investigative Services is not acting as my agent, but rather Empire Pacific Investigative Services is acting on behalf of ___________________

_____________________________________________________________________________

 ______________________________           ____________________________  

Signature (Full Legal Name)                       Date of Signature

______________________________            ____________________________  

Home Address                                               Social Security Number

This Waiver and Release of Liability has been read to me, I understand what it means and consent to taking the polygraph examination.

______________________________ 

Signature (Full Legal Name) 

______________________________

Witness