Application Ashcroft Inc.

250 East Main Street

For Employment Stratford, CT 06614
FOR CONSIDERATION ANSWER COMPELTELY AND ACCURATELY. DO NOT REFERENCE RESUME.

Date Social Security No.

Name (Print) Tel. No.

LAST FIRST MIDDLE INITIAL

Present Address
STREET CITY STATE ZIP

In case of emergency, notify

NAME ADDRESS PHONE

Have you ever applied for work at Ashcroft When? Where?

before?

Name any relatives and/or acquaintances employed by Ashcroft

How were you referred to Newspaper Agency Friend/Relative (specify) Other (specify)
Ashcroft?

Are you legally authorized to work in the U.S.? Yes No Are you under 18? Yes No

Driver’s License Number (Required for field sales) State

TYPE OF WORK DESIRED

Position you are applying for:

MANAGEMENT TECHNICAL OFFICE & CLERICAL OPERATIVE

Administration Technician Secretarial Machine Operator
Supervision Drafting Clerical Assembler
Tool Design Data Processing

PROFESSIONAL SALES/MARKETING LABORER CRAFTS

Accounting Inside General Machinist
Engineering Direct Trades
M.I.S. Setup Instruct
Calibrate

Shift Preferred Day 2nd 3rd Salary desired $ per

EMPLOYMENT HISTORY
Firm Name and Address Date from Date to Position and Duties Final Rate Reasons for Leaving

CHECK BELOW THE FACTORY OR OFFICE MACHINES AND EQUIPMENT YOU HAVE OPERATED

Drill Press Turret Lathe Laser Welder Shorthand _____WPM Software:

Acme Gridley Printing Press TIG Welder Typewriter _____ WPM _____________________
Milling Machine Punch Press Automatic Welding Mach. Personal Computer _____________________
Auto Turret Lathe Lift Truck Hand Torch/Welding Other________________ _____________________
Brown & Sharpe Numerical Control Mach. _____________________ _____________________ _____________________
 EDUCATION AND TRAINING

Circle highest grade completed in Grade School High School Tech School College Graduate School
each school category
1 2 3 4 5 6 7 8 9 10 11 12 1 2 1 2 3 4 1 2 3 4
School Name Location Course/Degree
Grade School
High School
Vocational, Technical, Military School
College
Graduate

MILITARY SERVICE

Have you served in the U.S. Armed Forces? Yes No Branch of Service Date: From To

Initial Rank Final Rank Special Training

List any other special courses, training or certifications you have completed an any professional/trade groups or organizations to which you belong that you
consider relevant to your ability to perform the job for which you applied:

PLEASE READ CAREFULLY BEFORE SIGNING THIS FORM

1. Regardless of whether or not I become employed by Ashcroft, I recognize about me or my employment with any former employer, except as
that this application is not and should be not be considered as a contract of noted below: (If none, write “None.”)
employment. I understand that employment at Ashcroft is on at at-will
basis, and that my employment may be terminated with or without cause,
and without notice, at any time, at my option or Ashcroft’s. I further ………………………………………………………………………………….
understand that no Ashcroft employee or representative has the authority to
enter into a contract regarding duration or terms and conditions of
employment other than an officer or official of Ashcroft, and then only by
means of a written document signed by that officer or official. ………………………………………………………………………………….

2. I understand that any offer of employment is contingent upon my signing
and agreeing to abide by Ashcroft’s Code of conduct, which requires,
among other things, disclosure of potential conflicts of interest, and the
Employee Invention Agreement which requires, among other things,
assignment to Ashcroft of any and all inventions related to my employment
with Ashcroft.
3. I authorized Ashcroft an/or its agent(s) to contact any of all of my former
employers or any of the references I have supplied to it, for the purpose of
verifying any information I have provided, and /or for the purpose of
obtaining any information including by not limited to financial information,
driving records, criminal and education whether favorable or unfavorable,
4. I understand that misrepresentations of any material fact by me in this
application can result in denial of employment or, upon subsequent
discovery, immediate termination of employment.
5. I recognize that any offer of employment is contingent upon the
successful completion of a Company physical examination which
includes DRUG SCREENING.
6. I understand that any offer of employment is also contingent upon my
ability to provide the documentation required by the Immigration
Reform and Control Act of 1986 to substantiate that I am legally
authorized to work in the United States.

APPLICANT’S SIGNATURE DATE WITNESS

ASHCROFT DOES NOT DISCRIMINATE AGAINST ANY EMPLOYEE OR APPLICANT FOR EMPLOYMENT BECAUSE OF RACE, RELIGION, ANCESTRY,
COLOR, AGE, SEX, DISABILITY, NATIONAL ORIGIN, MARITIAL STATUS, SEXUAL ORIENTATION, OR STATUS AS A DISABLED VIETNAM ERA
VETERAN OR VETERAN.

REFERENCES
Give the names and addresses of 3 persons who can be contacted for reference, excluding relatives.
Name Address Occupation Relationship Daytime Phone No.
 CRIMINAL HISTORY CHECK

NOTE TO APPLICANT: Due to the nature of certain positions at this company, a criminal background check may be necessary as part of our application process.
If you are advised that this is necessary concerning the position you are applying for, please provide the information requested below:

*PLEASE NOTE WHEN ANSWERING THE FOLLOWING QUESTIONS:

i. Under CT law employers may not require disclosure of an arrest, criminal charge or conviction for which records
have been erased;
ii. Any person whose criminal records were erased will be considered to have never been arrested or convicted for
such matter(s), and may swear so under oath concerning such erased records;
iii. The type of criminal records subject to erasure are those pertaining to:
• a finding of delinquency or that a child was a member of a family with service needs;
• a sentence as a youthful offender;
• a criminal charge that was dismissed or nolled;
• a criminal charge for which the person was found not guilty; and
• a conviction for which the person received an absolute pardon.

Have you ever been convicted* of a felony? Yes No

If you answered Yes above, please indicate below (or on a separate page, if necessary):

i. the dates(s) of the conviction(s)

ii. describe the circumstances and nature of the offense, and
iii. describe what rehabilitation you have been through concerning such conviction(s)

I hereby give permission for Ashcroft Inc., and its assigned agents to conduct a criminal background check for any record of a felony conviction. A
conviction record will not necessarily be a bar to employment, but factors such as recency, rehabilitation, and relatedness to fitness to perform the job
in question will be considered. I agree to fully cooperate in any such background investigation, and to sign any waivers or releases that may be
necessary to obtain access to relevant information. In the event that any custodian of data will not release reference information or criminal history
information directly to Ashcroft Inc., or its assigned agents, I agree to personally request such information to the extent permitted by law. I understand
that any conviction record(s) discovered during such investigation will be kept confidential and will not be disclosed to anyone expect those Ashcroft
Inc., personnel representatives with a need to know based on management responsibilities or involvement with the hiring process.

Applicant’s Name (PLEASE PRINT) Date

Applicant’s Signature (Do Not Print)

 PLEASE READ CAREFULLY

Applicant Authorization and Consent for Release of Information

Ashcroft Inc. truly welcomes your application. We’re proud that our success is the result of the quality
and caliber of our employees. In pursuit of that excellence we require as a condition of employment that
all applicants consent to and authorize a pre-employment verification of the background information
submitted on their application or resume.

I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of
employment is true and complete to the best of my knowledge. I understand that if I am employed any
false statements will be considered as cause for possible dismissal.

This release and authorization acknowledges that Ashcroft or its assigned agents may conduct a
verification of my education, previous employment/work history, credit history, motor vehicle records,
contact personal references, require that I successfully undergo a drug screen and may receive any
criminal history information pertaining to me which may be in the files of any Federal, State, or Local
criminal justice agency. The results of this verification process will be used to determine employment
eligibility under this Company’s employment policies and in no way will be used in violation of federal or
state equal opportunity laws.

I authorize Employment Reference Source, (hereinafter referred as “ERS”), and any of its
agents/designated Company Personnel, to disclose verbally and in writing the results of this verification
process and/or interview to the designated authorized representatives of Ashcroft.

I have read and understand this release and discharge the Ashcroft, its agent ERS, and their associates
to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or
any other charge or complaint filed with any agency arising from the retrieving and reporting of
information. A copy of this release is as good as the original. According to the Federal Fair Credit
Reporting Act, I am entitled to know if employment was denied based on the credit history information
obtained by my prospective employer, and to receive, upon written request, a disclosure of the public
record information and of the nature and scope of the investigative report.

APPLICANT:

_____________________________________ SS#________________________________
Name (typed or printed)
Date of Birth________________________
_____________________________________
Other Name Under Which Records Drivers Lic. #________________________
May be Listed (i.e., Maiden Name)
State_______________________________
_____________________________________
Signature High School _________________________

Year Graduated______________________
EMPLOYMENT VOLUNTARY DISCLOSURE

It is the policy of the Company to ensure equal employment opportunity for all employees and applicants,
regardless of race, color, religion, sex, national origin or age. Employment shall be based solely on the
Company's needs and the individual's qualifications.

In order to comply with reporting requirements under Federal Law, we ask you to voluntarily complete this
form. The information requested will be kept confidential and is not part of the employment application. It
will not be used for hiring, placement, or any other decisions relating to terms and conditions of employment.

Do not hesitate to ask for assistance if you have any difficulty completing this form. Thank you very much for
your cooperation.

DATE NAME - LAST FIRST MIDDLE

SOCIAL SECURITY NUMBER POSITION APPLIED FOR

RACE GENDER
White (Not of Hispanic Origin) Male
Black (Not of Hispanic Origin) Female
Asian or Pacific Islander - or -
American Indian or Alaskan Native I choose not to self-identify.
Hispanic
- or -
I choose not to self-identify.

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