Daily Express, Inc.

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Owner Operator
ONLINE APPLICATION

 

Daily Express Online Application

Daily Express, Inc.
PO Box 39, Carlisle, PA 17013
800-735-3136 : FAX 717-240-2195

 

Department of Transportation
Safety Clearance Form

* Note:  Use the tab key to move between fields, DO NOT hit the enter key until you are finished filling out the entire application.  Some information may be omitted unintentionally.

If you would prefer to receive an application by mail, click here.

 
Personal Information
First Name
 Middle Name
 Last Name
 Social Security #
Address Street
 City
 St
 Zip

Addresses for last three (3) years if different from above
Address Street
 City
 St
 Zip
Address Street
 City
 St
 Zip

Additional Information
Telephone Number - (include area code) 
Cell Phone Number - (include area code) 
Email Address
Are you a US Citizen?  Yes  No
Are you able to enter Canadian Provinces  Yes  No
Have you ever been convicted of a crime?  Yes  No
   If yes, where, when and the disposition of the offense.
   
Date of Birth  
Are you able to fluently read and speak English?   Yes   No
Do you wear Glasses or Contacts?   Yes   No
Do you have a valid DOT Physical?   Yes   No

Select last year of school completed
Grade School  123456

High School   789101112

College  12345

Name of special trade school attended (if applicable)

Graduated? YesNo

Driving Information
List all operators/chauffeurs/CDL licenses which have been issued to you or have been valid during the past ten (10) years.
      Class State Number Expiration
1.
2.
3.
Enter the number of years and months of experience that you have had while operating any of the following.  If you have no experience, then enter 'none' Tractor/Semi
 Tractor/Double
Flatbed
 Drop Deck
RGN
Do you have a double/triples endorsement on your CDL?   Yes   No 
If yes, have you operated longer combination vehices (Jeeps and Stingers) within the past 2 years?   Yes   No 

Check here if applying as a Company Driver

 

Tractor Information
Year
 Make
 Serial Number
Tire Size
 Wheel Base
 Engine Size
Axles
2
3
4		 Type
Conv
COE
Sleeper Berth		 Engine
Gas
Diesel
Jake		 Fifth Wheel
Sliding
Stationary		 Suspension
Spring
Air

Traffic Violations - in the PAST FIVE (5) YEARS (if none, state "none"): Include all violations other than for parking.  IT DOES NOT MATTER IF THEY HAVE BEEN REMOVED FROM YOUR STATE MVR OR NOT!
Violation Date Location Penalty
1.
2.
3.
4.

List ALL Accidents - in the PAST FIVE (5) YEARS in which you were involved, REGARDLESS OF WHO WAS CONSIDERED AT FAULT, WHO WAS ISSUED A CITATION, OR IF IT IS ON YOUR MOTOR VEHICLE RECORD OR NOT.  FAILURE TO LIST ALL ACCIDENTS DISQUALIFIES YOU FROM FURTHER CONSIDERATION FOR A CONTRACT!
1. Nature of Accident
 Date
 Location
 # of Injuries
 # of Fatalities

Details:

 
2. Nature of Accident
 Date
 Location
 # of Injuries
 # of Fatalities

Details:

 
3. Nature of Accident
 Date
 Location
 # of Injuries
 # of Fatalities

Details:

 
4. Nature of Accident
 Date
 Location
 # of Injuries
 # of Fatalities

Details:

 
Has your license, permit, or privilege to operate a motor vehicle ever been denied, revoked, or suspended?  Yes  No

If yes, complete below:

1. Facts and Circumstances
Date   State 
2. Facts and Circumstances
Date   State 

In Compliance with 49CFR part 40
  This question must be answered to process your application:
  During the past two years, have you 1) ever tested positive, or 2) refused to test on any pre-employment drug and alcohol test administered by an employer that you applied to, but did not obtain, safety-sensitive work?
   Yes  |   No

Personal References
Name City State Phone Occupation Place of
Employ-
ement		 Years
Known

Work Experience
Include all employers or business associates over the past ten (10) years.  If unemployed at any time, include those dates as well.  May we call your current employer?  Yes No

#1 - Employer
(most recent)
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional   |C.O.E   |DayCab   |Tandem   |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

#2 - Employer
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional |C.O.E |DayCab |Tandem |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

#3 - Employer
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional |C.O.E |DayCab |Tandem |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

#4 - Employer
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional |C.O.E |DayCab |Tandem |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

#5 - Employer
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional |C.O.E |DayCab |Tandem |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

#6 - Employer
 Telephone
 Who can we Contact?
Address (Street, City, State, Zip)
Dates From & To (Month/Year)
Were you subject to Federal Motor Carrier safety regulations for this company?
Yes    No 
Were you subject to alcohol and controlled substance testing requirements for this company?   Yes    No 
Hours or Miles Driven/Week
 Full-time
Part-time

Company Driver       Owner Operator          Non-Trucking Job

Types of Tractors Driven
Conventional |C.O.E |DayCab |Tandem |Four-Axle
Types of Trailers Pulled
Flatbed or Specialized Experience
How many Years/Miles
Over Dimensional Experience (if yes, how big)
Number of Accidents
 Explain Reason for Leaving

APPLICANT DISCLOSURE AND RELEASE

In connection with my request for Safety Clearance with Daily Express, Inc., I understand that an investigative report will be requested from any previous employer or consumer-reporting agency to be used at Daily’s discretion. This report will include information as to my character, work habits, results of drug and alcohol tests including pre-employment tests or test refusals from potential employers to which I had applied, performance and experience, along with reasons for termination of past employments or contracts from previous employers or business associates. Further, I understand that you will be requesting information concerning my driving record and/or information from various federal, state, and other agencies which maintain records concerning traffic offenses, accidents, etc. Other information will be obtained from previous employers or consumer reporting agencies concerning (1) previous driver record requests made by other such state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies; (4) and Workmen’s Compensation history on file in the state agency. I have the right to review, upon proper identification, information provided by previous employers and to have any errors in the information corrected by the previous employer and the right to issue a rebuttal statement. Requests must be submitted in writing to Daily Express, Inc. PO Box 39 Carlisle, PA 17013.

I AUTHORIZE, WITHOUT RESERVATION, ANY CURRENT OR PREVIOUS EMPLOYER TO FURNISH THE ABOVE-MENTIONED INFORMATION.  I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY A CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I hereby consent to your obtaining the above information from a previous employer or consumer-reporting agency to be used at Daily’s discretion. I also agree that such information which the consumer reporting agency has obtained, and my operational record while employed by you, or under contract with you, or while driving for a Fleet Owner in your service, if I receive safety clearance, will be supplied by Daily Express or a consumer reporting agency to other companies which subscribe to consumer reporting services.

I understand that the information in this Safety Clearance Form will be used and that prior business associates or employers will be contacted for purposes of investigation as required by §391.23 & CFR Part 40 of the Federal Motor Carrier Regulations. Also, I voluntarily agree to undergo a physical examination, including any drug or alcohol test or safety/performance profile test required by the federal safety regulations or this company. I further certify that this Safety Clearance Form was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge, recognizing that any falsification of the information I have provided, regardless of when discovered, will result in immediate disqualification and termination of my employment or contract.

I understand that any pre-lease or pre-hire approval given is a conditional approval. Final approval is subject to further review of my qualifications. If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment or contract period.

Please check here
By checking this box, I agree that I have read the above statement and verify that the information is true and correct to the best of my knowledge.  This is also the online equivalent of my signature.

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