Please enable JavaScript in your browser to complete this form. - Step 1 of 9CLASS OF MEMBERSHIP DESIRED: *InternAssociateMemberPERSONAL INFORMATIONLast Name *First Name *Middle NameDate of Birth *Place of BirthMAILING ADDRESSAddressCityStateZipNextCURRENT BUSINESS/EMPLOYER’S NAMECURRENT BUSINESS/EMPLOYER’S NAMECURRENT BUSINESS/EMPLOYER’S ADDRESSAddressCityStateZipPRESENT OCCUPATION/JOB TITLE:PRESENT OCCUPATION/JOB TITLE:NextCONTACT INFORMATIONHomeWorkCellPrimary Email *Secondary EmailWhere would you like AzPA correspondence mailed? *ResidenceBusiness/EmployerAMOUNT OF TIME DEVOTED TO POLYGRAPH WORKDays per week?Hours per Day?EDUCATIONName and Address of School Attended. Did you graduate? Type of Degree obtainedPOLYGRAPH TRAININGWhat is the name of the polygraph school you attended?What is the address of the polygraph school you attended?What were your basic examiner school dates of attendance?How many hours of instruction did you complete during your basic examiner course?What was the name of the primary instructor during your basic examiner course?How many polygraph examinations did you complete during your basic examiner course?What polygraph equipment do you currently use or have you previously used?How many continuing education hours have you completed in the last year? Three years?NextPOLYGRAPH EXPERIENCE (If more than 3, please use the Continuation page.)Name of employerAddressDates of employmentName of position heldTotal number pre-employment or screening exams completed in last 3 yearsTotal number of other exams completed in the last 3 yearsTotal number pre-employment or screening exams completed in last 3 years (copy)NextName of employerAddressDates of employmentName of position heldTotal number pre-employment or screening exams completed in last 3 yearsTotal number of other exams completed in the last 3 yearsNextName of employerAddressDates of employmentName of position heldTotal number pre-employment or screening exams completed in last 3 yearsTotal number of other exams completed in the last 3 yearsNextOTHER POLYGRAPH LICENSESStateNumberDates heldOTHER PROFESSIONAL ORGANIZATIONAL MEMBERSHIPSOrganization nameFrom when to when?MILITARY SERVICEBranchDates of ServiceDischarge TypeNextPlease answer the following question truthfully and completely. If additional space is needed, please utilize the Continuation Page at the end of this application.A. Have you ever been investigated or charged with a criminal offense? ( ) Yes ( ) No If yes, please explain below.B. Have you ever been refused a bond? ( ) Yes ( ) No ( ) N/A If yes, please explain below.C. Have you ever been discharged from any employment? ( ) Yes ( ) No If yes, please explain below.D. Have you ever been expelled from membership in any organization or society? ( ) Yes ( ) No If yes, please explain below.E. Have you now or have you ever been a member of a subversive organization? ( ) Yes ( ) No If yes, please explain below.F. Have you ever been denied/refused/revoked a professional membership of any organization? ( ) Yes ( ) No If yes, please explain below.G. Have you been fired for cause from a government agency? ( ) Yes ( ) No If yes, please explain below.NextREFERENCES (Please include names and addresses for 4 personal/professional references.I understand that I will not receive, and I am not entitled to information collected during the course of my application process, and I further understand the information collected will be used in the evaluation process for my membership with the Arizona Polygraph Association (AzPA). I affirm that I have completed this application on my own and for myself and information provided is truthful and honest. I agree to hold said Arizona Polygraph Association, its members, examiners, 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. I will be notified upon a successful preliminary review of my application and will provide sample polygraph charts for evaluation by the AzPA membership committee at which time I will also provide a $75.00 membership application fee via check or money order made payable to the AzPA. Applicant Signature *Date *Subscribed and sworn to before me this ( ) day *of *201.. *My commission expiresNotary Public Signature and SealTHIS APPLICATION IS NOT A GUARANTEE OF MEMBERHIP. ADDITIONALLY, THE APPLICANT MUST BE PRESENT AT AN AZPA MEETING/CONFERENCE IN ORDER TO BE VOTED INTO MEMBERSHIP. IF THE APPLICANT IS NOT AVAILABLE THEN THE VOTE FOR MEMBERSHIP WILL BE TABLED UNTIL THE APPLICANT IS PRESENT.CONTINUATION PAGEPhoneSubmit