STATE OF MAINEDepartment of Public Safety

MAINE CRIMINAL JUSTICE ACADEMY15 Oak Grove Road

Vassalboro, Maine 04989

John E. MorrisCommissioner

John B. RogersDirector

Paul R. LePage

Governor

Appendix 3MCJA Pre-employment Polygraph Report Form

(Please print all information)

Name of Applicant:_______________________________ DOB of Applicant:______________

Address of Applicant:____________________________________________________________

Employing or Sponsoring Agency: _________________________________________________

Date of Examination: __________ Examiner & License #_______________________________

Notification of Disqualifying ConductPursuant to Maine Criminal Justice Academy Board of Trustee entry standards, a polygraph examination of the individual named above was conducted at the request of the employer or sponsor. During the examination, the candidate admitted to conduct which is defined by the Board as disqualifying conduct.

Disqualifying conduct includes conduct as an adult, regardless of whether the applicant was charged or convicted, for which a waiver from the Board of Trustees is required. This includes:

1. Murder;2. Any Class A, Class B, or Class C crime;3. Conduct specified in 1 or 2 above in another state or other jurisdiction, which would be

disqualifying conduct, if committed in Maine. __________________________________________________________________

The above named applicant has been given a polygraph examination using the approved State of Maine Standardized Pre-employment Polygraph Examination for Law Enforcement Agency Applicants. (Please check off appropriate box).

Yes NoThe above named applicant fully completed the State of Maine Standardized Pre-employment Polygraph Examination for Law Enforcement Agency Applicants (please check off appropriate box).

Yes No

The above named applicant has admitted to disqualifying conduct as described above. (Please check off appropriate box).

Yes NoReturn this form for all Pre-employment Polygraphs conducted after 07/01/2003 to:

John B. Rogers, DirectorMaine Criminal Justice Academy 15 Oak Grove RoadVassalboro, ME 04989

OFFICE LOCATED AT: 15 OAK GROVE ROAD, VASSALBORO, MAINE 04989

(207) 877-8000 (Voice) (207) 877-8027 (Fax) TTY User: 711

STATE OF MAINEDepartment of Public Safety

MAINE CRIMINAL JUSTICE ACADEMY15 Oak Grove Road

Vassalboro, Maine 04989

John E. MorrisCommissioner

John B. RogersDirector

Paul R. LePage

Governor

Copy: Employer / Sponsor (Form: PE 1, revised 02/01/2011)

OFFICE LOCATED AT: 15 OAK GROVE ROAD, VASSALBORO, MAINE 04989

(207) 877-8000 (Voice) (207) 877-8027 (Fax) TTY User: 711