Employment Form

Redline Driver Application

Step 1 of 6

Date:
Date Format: MM slash DD slash YYYY
Referred by:
Name
CONTACT INFORMATION
Full Name:*
First Middle Last
Current Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If less than three years at the above address, list below all residences for the past three years.
Previous Address (if above less than 3 years):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Previous Address (if above less than 3 years):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone:
Cell Phone:
In case of Emergency contact:
Name Relationship Phone
Your Email:*
Social Security #:
Date of Birth:*
Date Format: MM slash DD slash YYYY
Date Available:
Date Format: MM slash DD slash YYYY
Drivers License #:*
License # State Class
Previous License # (if current # is less than 3 years):
License # State Class
DRIVING RECORD AND TRAINING
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
Have you ever driven a tractor and semi-trailer?*
- Yes
- No
Have you ever pulled a Refer?*
- Yes
- No
List special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?
List states operated in during the last three years:
Rate of pay expected:
Have you worked for Redline before?
- Yes
- No
If yes, when?
Accident Record for the past 3 years
Date Nature of Accident (Head-on, Rear-end, etc.) Fatalaties Injuries

Click the plus sign above to add more accident records if needed
Traffic convictions and Forfeitures for the past 3 years, other than parking violations
Location Date Charge Penalty

Click the plus sign above to add more traffic convictions if needed

EDUCATION
Last School Attended:
Highest grade completed:
Did you graduate from a truck driving school?
- Yes
- No
School name:
EMPLOYMENT HISTORY
(Please provide minimum of 10 years employment history)
Are you currently employed?
- Yes
- No
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #1
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #2
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #3
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #4
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #5
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #6
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #7
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #8
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #9
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:
Previous Employer #10
Employer name:
Employer Phone:
Starting Date:
Date Format: MM slash DD slash YYYY
Ending Date:
Date Format: MM slash DD slash YYYY
Address
Street Address Phone: City State / Province / Region ZIP / Postal Code Country
Position:
Reason Left:
Salary/Wage:

Background Report
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Red Line Inc. ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision lo not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days o f taking adverse action oral, written
or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper
identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. I f you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy o f the data by submitting a request to https://dataqs.fmcsa.dot, gov. I f you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless o f fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Red Line Inc. ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa-dot gov I f 1 challenge crash or inspection information reported by a State, FMCSA
cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report or assign, or imply fault, I acknowledge it will include all CMV crashes where l was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Signature to Authorize Background Report*
Printed Name:*
Date
Date Format: MM slash DD slash YYYY
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. LAST UPDATED 12/22/2015

PREVIOUS EMPLOYER ALCOHOL & DRUG TEST INFORMATION
Section 1: To be completed by prospective employee
Full Name
Name
Social Security #
Date of Birth
Application Date
Date Format: MM slash DD slash YYYY
Previous Employer
Employer Phone
Employer City & State
City State
Employer Fax
I HEREBY AUTHORIZE the above previous employer to release and forward the information requested by section 2 (below) of this document concerning my Alcohol and Controlled Substances testing records within the previous 3 years from date of application (above).Prospective Employer: Redline Inc., 2805 Bel Aire Drive, Emporia, KS 66801 (Phone: 620-343-1000 Fax: 620-343-1076). In compliance with §40.25(g) and 391.23 (h), release of this information must be made in written form that ensures confidentiality such as fax, e-mail or letter.
Signature
Date
Date Format: MM slash DD slash YYYY
Section 2: To be completed by previous employer
The section below will be sent your previous employers(s). It is not editable. Please scroll down and click NEXT to proceed.

If driver was not subject to Department of Transportation testing requirements when employed by this employer, please check here ______. Fill in the dates of employment from ______________ to____________. Please complete Section 2, sign, and return.

Driver was subject to Department of Transportation testing requirements from ___________________ to ___________________.

		YES	NO
1.	Has this person had an alcohol test with a result of 0.04 or greater alcohol concentration?	___	___
2.	Has this person had a verified positive drug test: (including verified adulterated or substituted drug test results)?	___	___
3.	Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?	___	___
4.	Has this person committed other violations of DOT agency drug and alcohol testing regulations?	___	___
5.	If YES was answered to any of the above questions, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If you, please send documentation back with this form.	___	___
6.	If employee successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?	___	___

In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years from the application date shown in Section 1.

Completed by Name: _________________________________ Signature: _____________________________________ Date: ___________

Company: __________________________________ Address, City, State, Zip: ____________________________________________________

Redline Inc. sent this form by: Fax _____ Email _____ Date ____________

INQUIRY TO PAST EMPLOYERS
The section below will be sent your previous employers(s). It is not editable. Please scroll down and fill in your name, social security number, and signature to authorize this inquiry.

TO: ___________________________________________ DATE: ______________________

FROM: REDLINE INC., 2805 BEL AIRE DR. EMPORIA, KS 66801
620-343-1000 • Fax: 620-343-1076

Personnel Manager:
The person named below has applied to Redline Inc. for employment. Your firm is listed by the applicant as a past employer. Will you kindly reply to this inquiry respecting this applicant? As you will note from the waiver stated below, all liability of you and your company has been released by the applicant.

Applicant is applying for a driving position with Redline Inc.

1. This applicant list dates of employment with your firm from: _____________ to_____________. Is this correct? Yes___ No___
If no, please explain: __________________________________________________________________________________________
_____________________________________________________________________________________________________________________

2. What kind(s) of work did he/she do? Driver______ Dock______ Office______ Other __________________________________

3. If employed as a driver, please indicate type of equipment: Tractor-trailer___ Straight Truck___ Bus___ Other___________

4. Number of accidents _______________ Number preventable ________________

5. To your knowledge, was this person’s commercial license suspended while in your employ? ___________
If yes please explain: __________________________________________________________________________________________
_____________________________________________________________________________________________________________________

6. Number of on–the-job injuries while in your employ:_______ Any recurring injuries:_______ Any back injuries:_______
Any award for permanent or partial disability ________________

7. Was this employee’s general conduct: Good ___ Average ___ Poor ___
in your opinion? _________________________________________

8. Why did this employee leave your company? Resigned ___ Discharged ___ Laid off ___

9. Would you re-employ this person? Yes___ No___ Please explain: ________________________________________________________
______________________________________________________________________________________________________________________________

10. Comments: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________

Completed by Name: _________________________________ Signature: _____________________________________ Date: ___________

I hereby authorize your company to release all records of employment, including assessments of my job performance, ability and fitness to Redline Inc. and their agents which may request information in connection with my application for employment. I hereby release your company from any and all liability of any type as a result of providing the above mentioned information to Redline Inc.

Applicant Full Name
Applicant Social Security #
Applicant Signature
Witness' Signature

Redline Driver Application

Step 1 of 6

CONTACT INFORMATION

DRIVING RECORD AND TRAINING

EDUCATION

EMPLOYMENT HISTORY

Previous Employer #1

Previous Employer #2

Previous Employer #3

Previous Employer #4

Previous Employer #5

Previous Employer #6

Previous Employer #7

Previous Employer #8

Previous Employer #9

Previous Employer #10

PERSONAL HISTORY

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability or any other protected group status.

Background Report

PREVIOUS EMPLOYER ALCOHOL & DRUG TEST INFORMATION

Section 1: To be completed by prospective employee

Section 2: To be completed by previous employer

INQUIRY TO PAST EMPLOYERS

Date	Nature of Accident (Head-on, Rear-end, etc.)	Fatalaties	Injuries

Location	Date	Charge	Penalty