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Pre-Polygraph
INTEGRITY
Questionnaire
Information contained in this booklet is to be reviewed only by
authorized personnel.
Note: Failure to accurately and truthfully complete this questionnaire in it’s entirety will
be cause to disqualify the applicant from further consideration for employment.
Revised 10/02
EMPLOYMENT STATUS
4. Have you ever quit a job to avoid being fired for any reason? Yes No
Explain:
ARMED FORCES
F. Were you ever given a court martial or had any type of disciplinary
action taken against you? Yes No
Remarks:
CREDIT INFORMATION
DRIVING RECORD
5. How many citations have you received in the past year? _______ Two years?______
Remarks (what was the violation(s)):
7. How many accident have you had in the past year? ________ Two years?_______
Total number of accidents you have ever been in?__________
Were there any injuries?
8. Have you ever operated any motor vehicle while under the influence of drugs or
alcohol, drove recklessly, or driven while under suspension? Yes No
If yes, for what violation and explain:
4. How many times have you smoked marijuana in the last twelve months?___________
Remarks:
5. How many times have you smoked marijuana in your entire life? ________________
Remarks:
6. Have you ever injected, or had injected, any illegal drugs into
your body? Yes No
Remarks:
10. Have you ever been present when any of the following were used,
but you did not use them? Yes No
Explain:
11. Have you ever purchased marijuana or any other type of illegal or
prescription drug not prescribed to you? Yes No
Explain:
12. Have you ever sold marijuana or any other type of illegal or
prescription drug? Yes No
Explain:
13. Have you ever bought an illegal drug or a prescription drug for
someone else? Yes No
Remarks:
15. When was the last time you used or possessed any illegal drug?
1. Have you ever been convicted of a Fish and Game violation? Yes No
Explain:
4. Have you ever committed any fish and game violation(s) Yes No
Explain:
1. Have you ever sexually fondled a child since you’ve been grown? Yes No
Explain:
3. Have you ever accepted or given any money for the act of prostitution? Yes No
Explain:
5. Have you ever forced someone to have sex with you, (rape)? Yes No
Explain:
4. Have you ever stolen any money from a place where you work(ed)? Yes No
Explain:
5. Have you ever stolen any property or merchandise form a place where
you work(ed)? Yes No
Explain:
6. Have you ever been with someone when they stole something from a
store? Yes No
Explain:
8. Have you ever broken into a house or business not under your control? Yes No
Explain:
9. Have you ever engaged in any type of fraud over the Internet? Yes No
Explain:
10. What is the most serious crime in which you were involved?____________________
_________________________________________________________________
_________________________________________________________________
11. Have you been completely truthful on your application for employment and during
the entire hiring process for the agency, you are currently seeking employment with?
12. If selected to continue in the hiring process, you will be required to take a polygraph
examination. Part of the polygraph examination process will be to verify whether or
not you have been completely truthful and honest with your prospective employee
throughout the hiring process, including this Integrity Questionnaire.