Schedule A Polygraph Examination Please use the form below to schedule a polygraph examination, or call us at (909) 918-6202. Schedule A Polygraph Examination Personal Information First Name * Last Name * Street Address * Street Address Street Address Street Address Street Address Street Address State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Street Address Company Information If this appointment is being made for an employee or perspective employee, please complete the following fields. If this doesn't apply to you, you can skip this section. Company Name Employee's First Name Employee's Last Name Date Of Birth Contact Information Cell Phone Number Work Phone Email Address * Appointment Information Purpose PurposeLaw Enforcement Pre-Employment ScreeningPost-Conviction Sex Offender TestingCorporate Theft & Embezzlement TestingChild Abuse, Domestic Violence or InfidelityAttorney-Client Pre-Court TestingOther Purpose Preferred Day * Preferred DayMondayTuesdayWednesdayThursdayFridayAs Soon As Possible Preferred Time Block Preferred Time Block * 8 am to 10 am 10 am to 12 pm 12 pm to 2 pm 2 pm to 4 pm Confirmation Confirmation * I understand all information will remain confidential and that by submitting this appointment request, this does not guarantee an appointment. This form only notifies Insight Polygraph Professionals of the desired date, time and purpose of an examination. Captcha Submit If you are human, leave this field blank.
