Personal InformationLast Name*First Name*Initial*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Main Phone Number*Email Address* Alternate Phone NumberAre you at least 18 years of age?* Yes No Referred ByPosition InformationWhat position are you applying for?*When are you available?*Wage/Salary Requirements*Have you ever been employed by the company before?* Yes No If yes, please answer the following questions.Dates EmployedPrevious SupervisorReason for TerminationEducation InformationName of SchoolCity/StateDegree or Grade CompletedMajor/SubjectsName of SchoolCity/StateDegree or Grade CompletedMajor/SubjectsEmployment HistoryName of CompanyCompany Address (City, State)Company Phone NumberLast Position HeldDuties and ResponsibilitiesSalary - StartingSalary - EndingStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Reason for LeavingName of CompanyCompany Address (City, State)Company Phone NumberLast Position HeldDuties and ResponsibilitiesSalary - StartingSalary - EndingStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Reason for LeavingName of CompanyCompany Address (City, State)Company Phone NumberLast Position HeldDuties and ResponsibilitiesSalary - StartingSalary - EndingStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Reason for LeavingConsent* I agree to these terms of employmentAPPLICANT’S CERTIFICATION AND AGREEMENT PLEASE READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT 1. Certification of Truthfulness: I represent that all my statements in support of my Application for Employment are true and complete. I understand and agree that if TACK Electronics, Inc., at any time, should determine that any requested information was withheld by me or any of my statements are false or misleading, I may be discharged. 2. Employment at Will: If hired by TACK Electronics, Inc., I agree to comply with all rules, regulations, policies, and communications directed to employees, including any changes made from time to time. I understand that I will be free to resign my employment at any time with or without cause, and with or without prior notice or warning to TACK Electronics, Inc.; I agree that TACK Electronics, Inc. also may terminate my employment at any time, with or without cause and with or without prior review, notice, or warning. 3. Limitation on Claims: I agree that any lawsuit against TACK Electronics, Inc. and/or its agents arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Right to Sue from the EEOC, within 90 days after the EEOC issues that Notice; or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit. 4. Authorization to Work: If I am selected for hire, I will be offered employment provided I certify and produce applicable documentation that I am authorized to work as required by the Immigration Reform and Control Act of 1986. 5. Need For Accommodation: If I, due to a physical or mental disability, require an accommodation to perform the job for which I may be selected, I understand that I must give TACK Electronics, Inc. written notice of that need within 182 days after I know or reasonably should have known that an accommodation is needed. Failure to do so may bar me from alleging that TACK Electronics, Inc. has not accommodated me as required by law. 6. Drug and Alcohol Testing: I agree to provide TACK Electronics, Inc. with appropriate specimens to test for the presence of drugs or other controlled substances if requested to do so for legal job-related purposes. I understand that decisions concerning my employment will be made as a result of these tests. 7. Physical Exam and Release of Medical Information: I understand that any job offer may be conditioned on passing a physical exam. I authorize every medical doctor, physician or other health care provider (HCP) to provide any and all information, including but not limited to medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I will cooperate in obtaining any additional authorization required by any HCP for release of any information. I hereby release every HCP and every other person, firm, officer, corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability for disclosure made pursuant to my authorization. I understand that medical information will not be requested from me, my physician or other HCP until a job offer has been made. 8. Disclosures: I agree that the contents of any offices, work spaces, desks, computer and computer generated data, any TACK Electronics, Inc. property I may be using, and any of my own property I bring onto TACK Electronics, Inc.’s premises, may be inspected by TACK Electronics, Inc. at any time it determines there is reasonable cause to do so, and I waive and promise not to make any claims against TACK Electronics, Inc. (or its employees or agents) relating to such inspection. I agree that, except as directed otherwise in writing by TACK Electronics, Inc., I will not disclose to anyone or use for my own purposes, any of TACK Electronics, Inc.’s confidential or proprietary information, either during or after my employment. I understand and agree that customer names and information, financial data, computer information and processes are confidential and proprietary information and I will not make written or other copies or notes regarding these matters except as necessary to perform my job. I agree that if I am hired and my employment ends, I will deliver to TACK Electronics, Inc. all material of any kind that I have relating to its business, including any such copies or notes. I agree that if any of the above commitments by me is ever found to be legally unenforceable as written, the particular agreement concerned shall be limited to allow its enforcement as far as legally possible. 9. Consideration for Employment: I agree to the above terms of employment if I am employed by TACK Electronics, Inc. Should I be employed, I understand and agree that these provisions of my employment can be revised only by a document signed by the President of the TACK Electronics, Inc., and that no person at TACK Electronics, Inc. other than its President has any authority to offer employment other than on an at-will basis as described above. I understand agree that, except as provided above, all compensation, benefits, programs, rules, and policies of TACK Electronics, Inc. are subject to exception or change at any time as decided by TACK Electronics, Inc. in its sole discretion. I understand that I may take this application form with me to submit at a later time if I choose to do so and that if I apply for employment, my application only will remain active for 60 days. If I have not heard from the TACK Electronics, Inc. by that time, the application is no longer “active” and I understand I must re-apply for employment. I acknowledge by my signature that I have been given adequate time to read, complete, and review my application and this certification, and I have knowingly and voluntarily signed below. I have read and understand the items listed in the Application for Employment, including this page, and acknowledge that with checking the box above.Today's Date* Date Format: MM slash DD slash YYYY Cover Letter/Resume This iframe contains the logic required to handle Ajax powered Gravity Forms.