Application for Employment

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:	*
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

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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