Quick Application

Personal Information
	Name (First, Last)
	Address:
	City:      State: AL AZ AR CA CO CT DE DC FL GA ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY      Zip
	Phone:      Social Security:      E-mail Address:
	License Number:      Expires / State Issued:     Birth Date:

License / Driving Record Information
	Do You Have 2 Years Tractor Trailer Exp. In The Past 5 Years?:	YES NO
	Do You Have A Hazardous Material Endorsement:	YES NO
	Do You Have A Doubles & Triples Endorsement:	YES NO
	Have You Had A DWI or DUI?:	YES NO
	Have You Ever Been Convicted Of A Felony?:	YES NO
	Referred by Jevic Driver:
	COMMENTS:
	I Authorize A DAC Background Check	Yes No
	Would you like an application packaged mailed to this address?	Yes No

Jevic Transportation, Inc (Headquarters) · 600-700 Creek Road · Delanco, NJ 08075 · 888-GO-JEVIC (888-465-3842)
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