The BEST Capabilities
The BEST Commitment
The BEST in Every Way
You WIN!


NOTE: Please print the following form directly from your browser. Fill it in completely and return via fax or mail to the fax number or address listed below. Upon completion feel free to return to the site by clicking here! Thank you for your interest in AKARD COMMUTATOR of TENNESSEE (ACT).
ACT MANAGEMENT, Inc.
AN EQUAL OPPORTUNITY EMPLOYER

(PRE-EMPLOYMENT QUESTIONNAIRE & AUTHORIZATION)
Date: ____________


PERSONAL INFORMATION
Name (Last Name First):
Present Address:

Permanent Address:

Social Security No.:
Telephone:
PAGER and/or CELLULAR:

[ __ ] Yes [ __ ] No

[ __ ] Yes [ __ ] No

EMERGENCY PHONE
EMERGENCY Contact



[ __ ] Yes [ __ ] No
 ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________
( _____ ) ______ - ____________
( _____ ) ______ - ____________ / ( _____ ) ______ - ____________

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN
THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?
ARE YOU 18 YEARS OR OLDER?

( _____ ) ______ - ____________
___________________________________________________________

WE MAY EXERCISE A RANDOM DRUG/ALCOHOL TEST POLICY!

Are you PRESENTLY taking ANY kind of MEDICATION (prescribed/otherwise):

List ALL:____________________________________________________


EMPLOYMENT DESIRED
Position:
Date You Can Start:
Salary Desired:






[ __ ] Yes [ __ ] No
[ __ ] Yes [ __ ] No
[ __ ] Yes [ __ ] No





[ __ ] Yes [ __ ] No

Referred By:
 ___________________________________________________________
______________________________
______________________________

We operate 24 Hours-A-Day, 365 Days-A-Year.

List ALL SHIFTS, DAYS or TIMES YOU are UNABLE to WORK:
___________________________________________________________

Are You Employed Now?
May we inquire of THEM?
Applied HERE Before? - When? _______________________

BRIEFLY describe YOUR WORK EXPERIENCE within POSITION APPLIED FOR:
___________________________________________________________
___________________________________________________________

Do YOU have YOUR OWN TOOLING and/or TOOLBOX:

___________________________________________________________


EDUCATION

Grammer School

High School

College, Business or Correspondence
Trade / Military

Special Certification
Apprenticeships
_______________, ________ /_____, _____, ______ ,____________________

_______________, ________ /_____, _____, ______ ,____________________

_______________, ________ /_____, _____, ______ ,____________________

_______________, ________ /_____, _____, ______ ,____________________

_______________, ________ /_____, _____, ______ ,____________________


FORMER EMPLOYERS



Most Recent or Current


Next Most Recent


Next Most Recent
 Started (m/y), Ended (m/y), Name & Address, Starting Salary, Ending Salary,
Position Title, Your Supervisor, Reason For Leaving

___/___, ___/___, _______________________________, $_______, $ _______
________________, ________________, ________________________

___/___, ___/___, _______________________________, $_______, $ _______
________________, ________________, ________________________

___/___, ___/___, _______________________________, $_______, $ _______
________________, ________________, ________________________

Which of the jobs listed did you like BEST?_______________
Why?_______________________________________________________

Which did you like LEAST?_____________________
Why?_______________________________________________________


GENERAL
SPECIAL SKILLS:
ACTIVITIES: (CIVIC, ATHLETIC, ETC..)



[ __ ] Yes [ __ ] No
[ __ ] Yes [ __ ] No
 ___________________________________________________________
___________________________________________________________
EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE,
CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ITS MEMBERS.

U.S. MILITARY or NAVAL SERVICE. - RANK:_____________

PRESENTLY in NAT'L GUARD or RESERVES.


REFERENCES - (NOT RELATED TO YOU - KNOWN FOR AT LEAST ONE YEAR)
NAME, ADDRESS, PHONE NUMBER, BUSINESS, YEARS ACQUAINTED
____________, ______________________, ________, ______________, ____
____________, ______________________, ________, ______________, ____
____________, ______________________, ________, ______________, ____
____________, ______________________, ________, ______________, ____


NON-COMPETITION CONTRACT PROPRIETARY MANUFACTURING
TECHNIQUES, CONFIDENTIAL INFORMATION, and TRADE SECRETS

In CONSIDERATION of CONTINUED EMPLOYMENT and OTHER VALUABLE CONSIDERATION that is hereby acknowledged, __________________________________ (hereinafter referred to as "Employee") shall not, for a set period of 2 (TWO) YEARS from the date of termination of his or her employment with ACT MANAGEMENT, Inc. (dba ACT & AKARD COMMUTATOR of TENNESSEE), request any customers of any business then being conducted or contemplated by ACT MANAGEMENT, Inc or its affiliates to curtail or cancel their business with ACT MANAGEMENT, Inc or its affiliates or perform work for any INDIVIDUAL or ORGANIZATION that PRODUCES and/or SELLS COMMUTATORS and/or SLIP RINGS or is otherwise deemed to be a competitor of ACT MANAGEMENT, Inc. EMPLOYEE FURTHER AGREES that he or she will be exposed to and/or instructed on PROPRIETARY MANUFACTURING TECHNIQUES, CONFIDENTIAL INFORMATION, and TRADE SECRETS (INCLUDING BUT NOT LIMITED TO MILLING TECHNIQUES & EQUIPMENT DESIGN, V-RING DESIGN & PRODUCTION TECHNIQUES, INTERNAL QUALITY CONTROL & PRODUCTION PAPERWORK, PRODUCT DESIGN PRINTS & THEORIES, QUALITY CONTROL MANUAL, COMPUTER AUTOMATED DESIGN SOFTWARE & FILES, CUSTOMER INFORMATION & BUSINESS ACTIVITY LEVELS, INTERNAL PROBLEMS, SOLUTIONS, & IMPROVEMENTS IN PROCESS, SPIN SEASONING/SPIN TESTING PROCEDURES & DESIGN, WAGE & BENEFIT INFORMATION, COMPUTER DATA, CUSTOMER LISTS, DAILY WORK ORDERS, JOB PRICING DETAILS, or ANY OTHER INFORMATION DEEMED VITAL AND PROPRIETARY BY ACT MANAGEMENT, Inc.) as a part of his or her normal duties. SUCH AGREEMENT SHALL EXTEND throughout the geographical area within a 500 MILE RADIUS of any present or future office opened by ACT MANAGEMENT, Inc. during the term of Employeeâs employment and the geographical area within a 500 mile radius of the Employee's home address. EMPLOYEE WAIVES any objection to the DURATION and GEOGRAPHY of such agreement and further promises not to institute any suit or proceeding, or otherwise advance any position or contention to the contrary. The Employee both acknowledges and agrees that the above restriction is reasonable as to duration and geography, and that such agreement is fully enforceable. EMPLOYEE HEREBY CONSENTS to the entry of temporary, preliminary, and permanent injunctive relief by any court of competent jurisdiction against him or her to restrain any such breach of the terms and conditions of this agreement, in addition to any other remedies or claims for money damages that ACT MANAGEMENT, Inc. may seek. The Employee recognizes that immediate and irreparable damage will result to ACT MANAGEMENT, Inc. if the Employee breaches any of the terms and conditions of this agreement and, accordingly, Employee agrees to render an equitable accounting of all earnings, profits, and other benefits arising from such violations. EMPLOYEE FURTHER AGREES to pay all costs and counsel fees incurred by ACT MANAGEMENT, Inc. in enforcing this agreement, which rights shall be cumulative. The Employee represents and warrants to ACT MANAGEMENT, Inc. that his or her experience and capabilities are such that he or she can obtain employment in business without breaching the terms and conditions of this agreement, and that his or her obligations under the provisions of this paragraph (and the enforcement thereof by injunction or otherwise) will not prevent him or her from earning a livelihood. In the event that a court of competent jurisdiction finds that this restrictive covenant and covenant not to compete is unenforceable in whole or in part for any reason, including, without limitation, the duration, scope, and remedies set forth above, then same shall not be void, but rather shall be enforced to the extent that same is deemed to be enforceable by said court, as if originally executed in that form by the parties hereto. EMPLOYEE FURTHER AGREES to notify the GENERAL MANAGER of ACT MANAGEMENT, Inc. immediately should he or she ever be contacted by another PRODUCER and/or SELLER of COMMUTATORS and/or SLIP RINGS, and provide details of such contact if it should take place for the duration of his or her employment with ACT MANAGEMENT, Inc. This agreement constitutes the complete and entire agreement between parties hereto and supersedes all prior negotiations, understandings, and agreements, whether oral or written, of any nature whatsoever with respect to the term of employment that is the subject matter hereof, and there are no representations, warranties, understandings, or agreements other than those expressly set forth herein between ACT MANAGEMENT, Inc. and the Employee. This agreement cannot be changed, modified, or terminated unless done so in writing and signed by the parties hereto. The validity, interpretation, construction, and enforcement of this agreement shall be governed in compliance with the laws of the State of Tennessee.

SIGNATURE:______________________________________ - DATE:_________________

ACT MANAGEMENT, Inc.
APPLICANT'S AUTHORIZATION & AGREEMENT

I hereby authorize ACT MANAGEMENT, Inc. and/or its agent to contact any listed SCHOOLS, FORMER EMPLOYERS, MEDICAL RECORDS, and/or PERSONAL REFERENCES for verification as a part of the application review process and I hereby authorize ACT MANAGEMENT, Inc. and/or its agent to conduct urine and/or blood DRUG TEST at its sole discretion prior to employment and/or at any time during any subsequent employment should I accept an offer of employment with ACT MANAGEMENT, Inc.

I certify that ALL the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to ACT MANAGEMENT, Inc. (ACT)'s rules, regulations, and policies, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or ACT MANAGEMENT, Inc.'s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by ACT MANAGEMENT, Inc. I understand that no ACT MANAGEMENT, Inc. representative, other than it's President, and then only when in writing, signed by the President, and including the raised corporate seal of ACT MANAGEMENT, Inc. (ACT), has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

SIGNATURE:______________________________________ - DATE:_________________


DO NOT WRITE BELOW THIS LINE

INTERVIEWED BY:
DATE:
TIME:
REMARKS:
ABILITY:
EXPERIENCE:
NEATNESS:

 [ __ ] Yes [ __ ] No
POSITION:
WAGE:

 [ __ ] Yes [ __ ] No
START DATE:

 [ __ ] Yes [ __ ] No


CHECKLIST:


Date:

INITIALS:
 HOLD____ FILE______
______________________________
______________________________
______________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

HIRED?
______________________________
______________________________

DRUG TEST?
______________________________

ANY SHIFT? ____________________
REVIEW: _____________________ [ ]

HOLIDAYS [__] BENEFITS [__] SAFETY & MSDS [__] VACATION [__]
POINTS [__] TOOLS [__] QUALITY [__] AVAILABILITY [__] FAMILY [__]

______________________________

______________________________

WITHHOLDING AGREEMENT

I hereby give permission for ACT MANAGEMENT, Inc. to withhold ANY/ALL WAGES necessary to cover costs of UNPAID, UNRETURNED, and/or DAMAGED: UNIFORMS, PAGERS, TELEPHONES, TOOLS, EQUIPMENT, SAFETY EQUIPMENT, VEHICLES, INSTRUCTION MANUALS, QUALITY MANUALS, MEASURING EQUIPMENT, MATERIALS, WORK-IN-PROCESS, COMPUTERS, CALCULATORS, DRAFTING EQUIPMENT, DRAWINGS, JOB PAPERWORK, DAILY WORK ORDERS, UNPAID INSURANCE PREMIUMS, UNPAID PERSONAL ITEMS ON ORDER, PERSONAL LONG DISTANCE TELEPHONE CHARGES, DESIGN PRINTS, CUTTING TOOLS, CUTTING INSERTS, JIGS, MOLDS, FORMS, DIES, CLAMPS, SUPPLIES, FACSIMILES, PHOTOCOPIES, or any other PROPERTY BELONGING TO ACT MANAGEMENT, Inc., its OWNERS, and/or its other EMPLOYEES in the event EMPLOYMENT IS TERMINATED for ANY REASON.

SIGNATURE:______________________________________ - DATE:_________________
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629 Universal Street - Alcoa, Tennessee 37701 USA
Phone 865.982.6369 - 800.889.2284 • Fax 865.982.7362 - 800.891.2284
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