Your Name (required)

Address

City

State

Zip

Are you 16 or older?
YesNo

Who referred you to Upcountry Provisions (optional)?

Your Email (required)

Your Telephone Number (required)

Type of Work Desired (can check more than one):
Full Time (32 hours+)Part Time (5-31 hours)SeasonalTemporary

Work Schedule Availability (check all that apply):
Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMSunday PM

Professional Reference #1 (Name and Contact Info)-

Professional Reference #2 (Name and Contact Info)-

Most Recent Employer (Business, Manager Name, Phone Number)-

Job Details (Dates of Employment, Job Title, Rate of Pay)

Previous Employer (Business, Manager Name, Phone Number)-

Job Details (Dates of Employment, Job Title, Rate of Pay)

Have you ever been convicted of a crime?
YesNo

If yes, please explain:

Please select the days you are available for an interview:
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Emergency Contact Name and Phone Number

I understand that if selected I would be participating in a “working interview” and that I am working at my own risk. If an incident occurs, I am responsible for all injuries and damages and not Upcountry Provisions. No pay will be given for this “working interview." During this interview, I could be asked to do a set of tasks that Upcountry Provisions does routinely. A Stage interview is a test and not training.