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Application for Employment

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Loffler Companies, Inc. is an equal opportunity employer and will not discriminate against any applicant for employment because of race, color, religion, gender, national origin, sexual orientation, disability, age, marital status or any other protected status. Applicants who require an accommodation throughout the application and interview process should request this in advance. Additional testing of job related skills may be required prior to employment. If you feel that you have been discriminated against during the application process, contact the Human Resources department at (952) 925-6830 or (800) 925-6830.

* indicates required fields

Position Applied For:  *
Other (specify): 
Social Security #:  - -
Last Name:  *
First Name:  *
MI: 
Address: 
City: 
State: 
Zip: 
Phone:  *
Alternate Phone: 
Email:  *
Verify Email:  *
Are you 18 years of age or older? yes no

If applying for a position which will require driving, please supply driver’s license number:
Have you ever been employed by Loffler Companies before? yes no
If yes, where & when?
Reason for leaving:
If hired can you furnish proof that you are eligible to work in the United States? yes no
Have you ever been convicted of a crime other than petty traffic offenses? yes no

If yes, please describe fully.
The existence of a criminal record will not necessarily bar an applicant from employment.

Educational History

  Name of School / Location Did You Graduate? Degree / Diploma Certificate Major
High School: yes
no
College or University: yes
no
Graduate: yes
no
Technical, Business or Vocational Training: yes
no
Additional job related seminars, short courses, workshops, or other educational experiences:

Military Background

Branch
of Service 		Military
Occupation 		Rank at
Discharge 		Specialized
Training

Work History

Include all employment from your last three employers with start and end dates. If you have a gap of employment, please explain below, including dates. Failure to provide complete information may result in rejection of your application.
MAY WE CONTACT YOUR PRESENT EMPLOYER? yes no
Present and Former Employers: LIST MOST RECENT FIRST
Company Name:

Job Title & Duties:
Address:

City, State, Zip:
Supervisor’s Name:

Phone:
Dates Worked: From: To:
Reason for Leaving:

Final Wage / Salary:
Company Name:

Job Title & Duties:
Address:

City, State, Zip:
Supervisor’s Name:

Phone:
Dates Worked: From: To:
Reason for Leaving:

Final Wage / Salary:
Company Name:

Job Title & Duties:
Address:

City, State, Zip:
Supervisor’s Name:

Phone:
Dates Worked: From: To:
Reason for Leaving:

Final Wage / Salary:
Company Name:

Job Title & Duties:
Address:

City, State, Zip:
Supervisor’s Name:

Phone:
Dates Worked: From: To:
Reason for Leaving:

Final Wage / Salary:

Special Skills & Qualifications:

Additional information you want us to consider in evaluating your qualifications:

Explain any gaps of employment here:

References

Please list a minimum of two current or past individuals who have supervised/managed you. Do not include relatives.
Name Company
Title
Phone

PLEASE READ CAREFULLY:

As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, and disability status on this form.

Providing this information is completely voluntary. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment.

The information you provide will be used only to monitor our compliance with equal opportunity laws and regulations, and for no other purpose.* When we receive this form, we will immediately place it in a confidential file separate from your application. If you wish, you may mail this form to us in an envelope separate from the one that contains your application.

Race/Ethnicity – Select one or more

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
   
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
   
Black or African American: A person having origins in any of the black racial groups of Africa.
   
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
   
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
   
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Disability – Are you a person with a disability?

Yes
No

Sex – Select one

Female
Male

* This form is not used for employment decisions. If you have a disability and need an accommodation so that you can perform the duties of the job for which you are applying, please notify us in some other manner.

AGREEMENT – PLEASE READ CAREFULLY ENTIRE STATEMENT BELOW

I certify that the facts set forth in this application are true and complete, to the best of my knowledge. I acknowledge that Loffler Companies, Inc. (hereafter referred to as “The Company”) may rely on my representations in this application in making its hiring decision. I understand that any false statement or omission of information submitted on this application may result in my not being hired or, if discovered later, my immediate discharge.

I authorize investigation of all statements contained herein and authorize the references and previous employers listed above to give THE COMPANY any and all information requested concerning my previous employment and any pertinent information they may have, personal or otherwise. I understand that the results of such an investigation may be used to determine whether I will be hired. I hereby release said references, investigators, previous employers and THE COMPANY from all liability for any damage that may result from furnishing or receiving this information.

I further agree that, if employed, I will conform my conduct to THE COMPANY rules and understand that my employment is “at will” and can be terminated with or without cause, and with or without notice, at any time, at my option or the option of THE COMPANY where applicable. I also understand that this application and any employment manuals or handbooks that may be distributed to me during my employment shall not be regarded as a contract.

Should an offer of employment be made and accepted, I will be required to sign and abide by an Employment Agreement, which includes confidentiality requirements and a non-compete clause as a condition of employment.

In the event of termination of my employment, whether voluntary or involuntary, I authorize THE COMPANY, in its sole discretion, to supply my name, address and phone number to other divisions, companies, services or agencies which may have employment opportunities.

I AGREE *

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