Printable Maryland Polygraph Police Template

The Maryland Polygraph Police form is a document required for individuals seeking employment with the Maryland State Police. This form serves as a prerequisite for a pre-employment polygraph examination, which assesses the truthfulness of the information provided by applicants. Completing this form accurately is crucial, as any misrepresentation may lead to disqualification from the hiring process.

To proceed with your application, please fill out the form by clicking the button below.

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Printable Maryland Polygraph Police Template

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Assigned to: _____________________

Tracking 67# ____________________

MARYLAND STATE POLICE APPLICANT POLYGRAPH SCREENING BOOKLET

Position Applied For:

Trooper Cadet

Civilian

Allied Agency

Other_

Have you received a written Conditional Offer of Employment? Yes No

INSTRUCTIONS TO APPLICANT:

You are being considered for employment with the Maryland State Police. As a prerequisite for employment, you are required to submit to a pre-employment polygraph examination. As part of that process, it will be necessary for you to complete this booklet. The contents of this booklet are held "CONFIDENTIAL," except when essential to the conduct of proper official police business and national security. It is important that you understand that the intentional misrepresentation, omission, or falsification of any material fact may be just cause for disqualification or dismissal from the applicant process.

Maryland State Police employees, regardless of position, are placed in a position of trust and responsibility. Because of this trust, the MSP expects candor and honesty from all employees. The purpose of this examination is to determine the truthfulness of the information provided to the polygraph examiner. The areas of inquiry will deal with your background and experience.

During the interview with the polygraph examiner, you will discuss many aspects of your background. Some may seem so "bad" that you are afraid it will disqualify you from this job. What will disqualify you is your failure to provide truthful, accurate, and complete information.

The next page is your written permission for the examiner to administer your examination. Do not mark on the page except to sign it in the lower right corner marked "signature."

Name (Last, First Middle) ________________________________________________________

Date of Birth_____________ Driver's License Number / State ____________________________

Mailing Address _______________________________________________________________

City ________________ County ______________ State __________ Zip Code ___________

Telephone: Home________________ Work _______________Cell Phone ________________

E-mail address ________________________________________________________________

Current Employer ______________________________________________________________

Employment Address ___________________________________________________________

City ________________ County ______________ State __________ Zip Code ___________

Date Booklet Completed: ___________________

MSP 40-23 (05-17)

1

RELEASE

I hereby voluntarily submit to a polygraph examination (detection of deception) by the Maryland State Police. I understand and agree that the polygraph examination will be audio and video recorded and that the recordings as well as the results of the polygraph examination may be made available to the proper authorities, including but not limited to other law enforcement agencies, social service agencies and current or past employers. In consideration of being given a polygraph examination without cost to me, I, for myself, my heirs, personal representatives and assigns, hereby agree to hold harmless, the Maryland State Police, its officers, employees, and agents from any liability for any damage to me as a result of said examination and I hereby remise, release, waive, and forever discharge and exonerate said Maryland State Police, its officers, employees, agents from any and all action or cause of action, claim, or demand which I have now or may ever have resulting directly, indirectly, or remotely from said examination or making known any reactions, statements, information, and incidental opinions made by me as part of the examination.

In witness whereof, I have hereunto set my hand and seal the day and date set forth above.

_________________________________	____________________________
WITNESS	SIGNATURE / DATE

MSP 40-23 (05-17)

2

SECTION A: PERSONAL BACKGROUND INFORMATION

PART 1: IDENTITY

Full Name: (Last, First Middle):____________________________________________________________________

Date of Birth: _________________ Race:________ Gender:_________ Place of Birth: _____________________

Social Security Number: _________________________________________________________________________

Scars, marks, or tattoos: (explain any significance) ____________________________________________________

_____________________________________________________________________________________________

Excluding nicknames, list any other names you have ever used and the periods of time you used them:

_________________________________________________________________________________________________

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

9.

Has your name ever been changed by court order?

Have you ever used a false name, date of birth, or place of birth for any reason? Have you ever obtained, possessed, or used any form of false identification? Have you ever used a false Social Security Number or someone else’s SSN? Have you ever misrepresented your identity to any law enforcement agency? Have you ever falsified your identity on any job application?

Have you ever falsified your identity on any credit application?

Have you ever falsified your identity on any other application or official document?

While underage, did you ever use any type of false identification to buy alcoholic beverages?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 1 - IDENTITY:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

3

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 2: CITIZENSHIP

YES NO

____ ____ Have you ever held citizenship in any country other than the United States?

IF YOU ANSWERED “YES” TO THE ABOVE QUESTION, YOU MUST ALSO ANSWER THE BELOW QUESTIONS ON THIS PAGE. IF YOU ANSWERED “NO” TO THE ABOVE QUESTION, YOU DO NOT HAVE TO ANSWER THE BELOW QUESTIONS ON THIS PAGE. PROCEED TO SECTION A, Part 3 (page 6).

Excluding the United States, list all foreign countries where you have held citizenship and the periods of time for each:

_________________________________________________________________________________________________

In what country were you born?________________________________________________________________________

At what age did you leave your country of birth? _________ At what age did you come to the U.S.?_______

Why did you leave your country of birth?_________________________________________________________________

Why did you come to the U.S.?________________________________________________________________________

With whom did you come to the U.S.?___________________________________________________________________

To what country do you hold your primary allegiance (loyalty)? _______________________________________________

YES NO

1.

2.

3.

4.

5.

6.

7.

Have you ever worked for a foreign government or foreign law enforcement agency? Have you ever been a member of a foreign military service?

Have you ever worked for, or been affiliated in any way, with a foreign intelligence agency? Are you now a Naturalized United States Citizen?

Have you provided this department with a valid Naturalization Certificate? Do you possess a valid passport issued by a foreign country?

Have you taken part in committing any crime(s) in another country?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 2 – CITIZENSHIP:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

4

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 3: RESIDENCY

List your current home address: _______________________________________________________________________

List any other addresses where you stay on a regular basis: _________________________________________________

_________________________________________________________________________________________________

	YES		NO
1.				Have you ever been evicted or threatened with eviction from any places you have lived?


2.				Have you ever had a mortgage foreclosure taken against you?


3.				Excluding eviction or foreclosure, have you ever been ordered to vacate any place you have lived?


4.				Have you ever been forced to vacate housing at any colleges due to disciplinary problems?


5.				Have you ever received a notice to appear in Landlord-Tenant Court?
5.
6.				Do you reside at any other address on a regular basis?
6.				Do you reside at any other address on a regular basis?

7.		____	____	Have you ever broken a lease at any place you lived?
7.		____	____	Have you ever broken a lease at any place you lived?
8.				Have any liens been placed against any property you have owned?
8.
9.				Have you had any police contact while leasing or renting?


10.				Have you been involved in any arguments or fights with any of your neighbors?
10.
11.				Will any of your current or former neighbors say anything derogatory about you?


12.				Have you ever moved out of any place you have lived due to arguments or disputes with your spouse,
12.
				family members, roommates, neighbors, or landlords?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 3 - RESIDENCY:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

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SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 4: EDUCATION

Name of High School Attended: ________________________________ Dates Attended: ______________________


Address: ______________________________________________________ Diploma Received: Yes	No
	No

Highest Grade Completed: ______ Graduation Date: __________ High School Equivalency (GED): Yes		No
		No

COLLEGES / UNIVERSITIES ATTENDED (Include name, address, # of credit hours, major, degree received)

1.

2.

3.

4.

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Were you ever suspended or expelled from any type of learning establishment for any reason? Did you ever have any adverse contact with high school security or school police?

Were you ever taken into custody or charged with any crimes by high school security or police? Did you ever have any adverse contact with college campus security or college police?

Were you ever taken into custody or charged with any crimes by campus security or police? Were you ever questioned as a suspect in any crimes by campus security or police?

Were you ever ineligible to return to any high school or college due to disciplinary reasons? Were you ever barred from entering the property of any high school or college?

Did you ever have any adverse contact with any resident assistants?

Were you ever required to appear before any college hearing board as a result of disciplinary action? Did you ever cheat on any exams, tests, assignments, projects, or papers in high school or college? Were you ever caught cheating in any educational or training environment?

Did you ever falsify your high school or college grades or grade point average? Did you ever falsify any information on your high school or college transcripts? Did you ever have any academic/disciplinary probations in high school or college?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 4 - EDUCATION:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

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SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 5: EMPLOYMENT

Please list places of employment starting from most recent. Also include dates employed. (If needed, use additional space provided in the remark sections)

1.

2.

3.

4.

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

_

	Have you ever been fired from any job?
	Have you ever been allowed to resign from any job in place of being fired?
	Have you ever quit any job because you thought you were going to get fired?
_	Are you ineligible for rehire at any place of employment now?
	Have you ever been denied any merit increases due to poor performance evaluations?
	Have you ever been involved in any physical or verbal confrontation with any coworker, supervisor,
	or customer?
	Have you ever quit any job due to allegations of misconduct on your part?
	Have you ever received any written disciplinary action on any jobs?
	Have you ever been suspended (with or without pay) from any job?
	Have you ever been investigated for any criminal acts against any of your employers?
	Have you ever been involved in industrial or corporate espionage?
_	Have you ever committed any criminal acts against any of your employers or coworkers?
	Have you ever deliberately violated any serious employment rules or regulations?
	Have you ever deliberately violated any employment nondisclosure agreements?
	Have you ever been denied employment due to adverse results of a background investigation?
	Have you ever applied to any police department or law enforcement agency?
	Have you ever been employed by any police department or other law enforcement agency?
	Have you ever been rejected for employment by any police department or law enforcement agency?
	Have you ever had any prior polygraph examination? If “Yes”, list when, where, and results.
	Have you ever before made application for employment with the Maryland State Police? If yes, when,
	what position, and what is the status of that application.

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 5 - EMPLOYMENT:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

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SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 6: FINANCES / CREDIT / LAWSUITS

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

Have you ever declared bankruptcy?

Have any court ordered financial judgments ever been taken against you? Have you ever had any property repossessed?

Have you ever had any accounts taken over by a collection agency? Are any of your current debts or bills 30 or more days delinquent? Have any liens been placed against any property you have owned?

Have you ever been sanctioned by the IRS or any state income tax agency? Do you have any alimony or child support obligations?

IF YOU ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS, STATE WHAT SPECIFIC ACTIONS YOU TOOK OR ARE NOW TAKING TO RESOLVE THESE FINANCIAL PROBLEMS.

_________________________________________________________________________________________________

YES NO

9.

10.

11.

12.

13.

Have your wages ever been garnished?

Has anyone ever sued you?

Have you ever sued anyone?

Have you ever received any out of court settlements?

Have any of your bank accounts ever been garnished or frozen?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 6 - FINANCES / CREDIT / LAWSUITS:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

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SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 7: MILITARY SERVICE

YES NO

1.

2.

3.

4.

Have you ever served in any branch of the Unites States military? Have you ever been rejected by any branch of the military?

Have you ever served in, or attempted to enlist in, any branch of a foreign military? Have you registered for selective service?

IF YOU SERVED IN THE MILITARY (U.S. OR FOREIGN) YOU MUST ALSO ANSWER THE FOLLOWING QUESTIONS. IF YOU HAVE NOT SERVED IN THE MILITARY, YOU DO NOT HAVE TO ANSWER THE BELOW QUESTIONS AND CAN NOW PROCEED TO SECTION 8.

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

Did you receive an Honorable Discharge? (IF NO, EXPLAIN)

Were you ever court-martialed?

Did you ever receive any nonjudicial punishments (written or verbal reprimand, etc.)? Were you ever questioned as a suspect in any crimes by any U.S. or foreign military police? Did you ever have any adverse contact with any U.S. or foreign police?

Were you ever denied eligibility for re-enlistment?

Were you ever charged with any violations of the Uniform Code of Military Justice (UCMJ)? Have you ever altered a copy of your DD-214 during any pre-employment investigation?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 7 - MILITARY SERVICE:

_________________________________________________________________________________________________

MSP 40-23 (05-17)

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SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 8: DRIVER’S LICENSE / RECORD / ACCIDENTS

YES NO

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Have you ever operated a vehicle after consuming any intoxicating substance to the point of impairment?

Have you ever operated a vehicle after consuming any intoxicating substance to the point of intoxication?

Have you ever fled from, or attempted to elude, police while on foot or in a vehicle? Have you ever operated a motor vehicle knowing it was uninsured / unregistered? Have your license plates ever been confiscated by the police or MVA?

Has your vehicle insurance ever been canceled or denied renewal? Have you ever failed to appear in court as a result of any traffic ticket? Have you ever received any traffic tickets as a result of a traffic accident? Have you ever been involved in any law-suit as a result of a traffic accident? Have you ever been involved in a hit and run accident?

Have you ever lied to any police officers to try to get out of a traffic ticket?

Have you ever lied to a judge in traffic court?

Do you currently have any traffic or parking tickets for which you have not paid the fine or appeared in court for?

Have you ever had a driver’s license in any other state? If so, list the periods of time for each? Have you ever filed to have any violations expunged from your driving record? If so, explain.

List below all traffic stops in this state or any other state that resulted in you receiving any of the following: citations, written warnings, verbal warnings, Safety Equipment Repair Orders, red light tickets, speed camera tickets.

DATE

STATE

VIOLATION(S)

DISPOSITION

MSP 40-23 (05-17)

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Fact Name	Fact Description
Purpose of the Form	The Maryland Polygraph Police form is used to assess the truthfulness of applicants for employment with the Maryland State Police.
Confidentiality	All information provided in this booklet is confidential, except when necessary for police business or national security.
Consequences of Misrepresentation	Providing false information can lead to disqualification or dismissal from the application process.
Employment Positions	The form is applicable for various positions including Trooper, Cadet, Civilian, and Allied Agency roles.
Governing Law	The use of polygraph examinations is governed by Maryland law, specifically under the Maryland State Police guidelines.
Audio and Video Recording	The polygraph examination will be recorded both audio and video for accuracy and transparency.
Personal Background Information	Applicants must provide detailed personal background information, including identity, citizenship, and residency history.
Signature Requirement	Applicants must sign the form to grant permission for the polygraph examination, indicating their understanding of the process.
Section Structure	The form is divided into sections that require information on identity, citizenship, and residency, among others.
Release of Liability	Applicants agree to hold the Maryland State Police harmless from any liability related to the examination.

Printable Maryland Polygraph Police Template

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