Canadian Armed Forces Military Personnel Instruction 01/13 – Annexes – Polygraph screening examination of Canadian Armed Forces members by other Government of Canada departments and agencies
| Name of CAF member (Print): | Service number: |
| Name of Government department or agency: | |
| Initials of the CAF member | |
|---|---|
| I, the undersigned, have read and understood the CAFMPI 01/13 including the information and notices identified below. | |
| I voluntarily make application for attachment, secondment, exchange or loan and have been informed of the requirement to submit to a pre-employment polygraph examination to assess my loyalty to Canada as a condition of employment. | |
| I undergo this pre-employment polygraph screening examination voluntarily, based on my desire to pursue this employment opportunity. | |
| I understand that this pre-employment polygraph screening examination will be audio or audio video recorded. | |
| I declare that I will provide information during the pre-employment polygraph screening examination that is up-to-date, accurate, complete and honest to the best of my knowledge and belief. | |
I understand that the consequences of my not being completely honest and forthright during the pre-employment polygraph screening examination may result in:
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| I understand that disciplinary or administrative investigations or actions cannot be taken against me based solely on the results of a pre-employment polygraph examination. However, security investigations may be commenced or disciplinary or administrative investigations or actions may be taken against me based on my admissions and/or statements provided during a pre-employment polygraph examination. | |
| I understand that I can voluntarily withdraw my consent to submit to a pre-employment polygraph examination at any time prior to the test. | |
| I consent to my information being used for security screening pursuant to the Treasury Board Policy on Government Security. |
| Date: | Signature of CAF member: |
| Place: | Signature of witness: |
Distribution: Member's Personnel File, Departmental Security/Personnel Security Screening Office, Member