EMPLOYEE REQUEST Please complete your request below. Step 1 of 18 5% Request Type* Payroll Help Availability Change Work Order Request Personal Information Change Anonymous Suggestion/Comment Box Time Off Request (not LOA) eID Help Work Permit Status Change Voluntary Go Home Notice Leave of Absence (LOA) Request Location Change Request Pregnancy Notification Paid Time Off Request Resignation Form Missing Hours Request Uniform Request Mileage Tracking Name First Last Not requiredEmail Not requiredPhoneNot required Request Submitted ByIf submitting for yourself, there is no need to complete this field.Employee Name* First Last Email for Confirmation and Response* Employee Time Card Number*Last 4 Employee SSN*Restaurant*Pick OnePacific Ave #802Wilson Way #969Lower Sacramento Road #3017Lodi Avenue #3580Charter Way #4111Tracy Blvd #4147Ben Holt #4643Elk Grove Blvd #4804Center Street #6216Waterloo Road #7058Louise #8195Floyd #10338Kettleman Lane/99 #10555Galt #10852March Ln. & West Ln. #1179711th Street #12264Tracy WM #13201Martell #13329Flag City #14444Manteca Walmart #15019Laguna #17476Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895Trinity Parkway WalMart #30912Stockton WalMart #31015ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681GSRG #1000GSRG Type*OfficeBoardOperationsMaintenanceOtherAcknowledgment* I certify that the information submitted is true and correct to the best of my knowledge First Day of Requested Leave* Date Format: MM slash DD slash YYYY Last Day of Requested Leave* Date Format: MM slash DD slash YYYY Type of Leave Requested*Family Medical Leave (FMLA)Employee Medical Leave (FMLA)Pregnancy Disability Leave (PDL)California Family Rights Act Leave (CFRA)Personal LeavePersonal Leave Notice* The following applies to Personal Leaves: • Personal leaves require a three (3) week notice • All correspondence and/ or requests can be faxed to (209) 938-1319, emailed to benefits@mcdgs.org, or mailed to: Benefits Department, 4502 Georgetown Place, Stockton, CA 95207 • It is the employee’s responsibility to submit all correspondence and/or LOA requests to the Benefit Department • For help or questions please call (209) 938-1257 I agree and understand the Personal Leave Notice FMLA, PDL, or CFRA Leave Notice* The following applies to FMLA, PDL, CFRA Leaves: • If you have a doctor’s note, please attach it to the LOA Request Form • If you do not have a doctor’s note, you must provide a doctor’s note within 15 days from your first day of absence • It is the employee’s responsibility to submit doctor’s notes and/or LOA requests to the Benefit Department • All correspondence and/ or doctor’s notes can be faxed to (209) 938-1319 or mailed to: Benefits Department, 4502 Georgetown Place, Stockton, CA 95207 • For help or questions please call (209) 938-1257 I agree and understand the FMLA, PDL, or CFRA Leave Notice Doctor's Note UploadAre you traveling during your leave?*YesNoAre you traveling out of state?*YesNo 1. Persons arriving in California from other states or countries, including returning California residents, should practice self-quarantine for 14 days after arrival. These persons should limit their interactions to their immediate household. This recommendation does not apply to individuals who cross state or country borders for essential travel. [2] 2. Californians are encouraged to stay home or in their region and avoid non-essential travel to other states or countries. Avoiding travel can reduce the risk of virus transmission and bringing the virus back to California. [1] “Non-essential travel” includes travel that is considered tourism or recreational in nature. [2] “Essential travel” includes: work and study, critical infrastructure support, economic services and supply chains, health, immediate medical care, and safety and security.Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employee Email* Please enter a working email address. You should expect email communication from the Benefits Department regarding your request.Phone*Comments*Employee Signature* Type of Permit Update*Permit RenewalPermit ChangeCurrent Work Permit Expiration Date* Date Format: MM slash DD slash YYYY New Work Permit Expiration Date* Date Format: MM slash DD slash YYYY New Work Permit*School/School District Providing Work Permit*Type of Work Permit*StandardWork Experience Location Change Disclosure*This is a request to change restaurant locations. Your request will be sent to the appropriate individuals to determine next steps. I understand and agree to the Location Change Disclosure Requested New Restaurant*Pick OnePacific Ave #802Wilson Way #969Lower Sacramento Road #3017Lodi Avenue #3580Charter Way #4111Tracy Blvd #4147Ben Holt #4643Elk Grove Blvd #4804Center Street #6216Waterloo Road #7058Louise #8195Floyd #10338Kettleman Lane/99 #10555Galt #10852March Ln. & West Ln. #1179711th Street #12264Tracy WM #13201Martell #13329Flag City #14444Manteca Walmart #15019Laguna #17476Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895Trinity Parkway WalMart #30912Stockton WalMart #31015ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681Reasoning for Request* Employee Resignation Please complete the below resignation form for your Employee Record.Current Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Last Day You Plan to Work* Date Format: MM slash DD slash YYYY Reason for Resignation*Another JobChild CareMedicalPermanent DisabilityPersonalRelocationRetirementLocation of Other JobReason for RelocationMovingSchoolFamilyLocation of RelocationComments for Resignation LetterSignature* Shift Date* Date Format: MM slash DD slash YYYY Scheduled Shift Start Time* : HH MM AM PM Scheduled Shift End Time* : HH MM AM PM Leaving Time* : HH MM AM PM Reason for Leaving Early*Temperature When LeavingI left my shift early voluntarily:* What help do you need?Do you also need to update your personal information?*YesNo Time Off Request Notice*Business needs will be considered when granting Schedule Request Time Off. You further understand that by completing this Schedule Request Time Off Form you agree to return to work on date below. If you do not return to work on return date, your position will be terminated as job abandonment. NOTE: Completing this form does not automatically generate an approval for your time off request. I understand that completing this form does not automatically generate an approval for my time off request. Restaurant Employee Disclosure*If the restaurant schedule is currently posted for the days you are requesting off, you may be responsible for finding coverage for your shifts. Requests are taken on a first come, first served basis and the business needs are taken into account for approvals. In order to complete schedules in a timely manner, it is requested that all Time Off Requests be submitted at least 2 weeks prior to the date requested off. I understand and agree to the Restaurant Employee Disclosure Are you a Restaurant Manager?*YesNoIs this leave COVID related?*YesNoRequested Leave Start Date* Date Format: MM slash DD slash YYYY Requested Leave End Date* Date Format: MM slash DD slash YYYY I agree to return to work on...* Date Format: MM slash DD slash YYYY Reason for Requested Time OffSignature* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Please provide your notification:*Shoe Size*Shoe Type*RegularWide Equipment TypeIssue:*Troubleshooting Steps Previously Completed:*Error CodesPicture of Equipment or ErrorIs this construction related?*YesNoNot Sure Paid Time Off Request Type*Accrued CA Sick LeaveSignature*Accrued CA Sick LeaveAny late requests will be reviewed on the next pay period following request.I am requesting to use accrued paid sick leave available under California law for the following reason:*Preventative care*, diagnosis, care, or treatment of an existing health condition for myself or a family member**I am a victim of domestic violence, sexual assault, or stalking and seeking care, psychological counseling, shelter, or support services, safety-related measures, or any relief, including restraining orders, to help ensure the health, safety, or welfare of myself or my child(ren)*Preventative care may include self-quarantine due to potential or actual exposure to COVID-19 or travel to a high-risk area. **A family member is defined as a child, parent, spouse, registered domestic partner, grandparent, sibling.Scheduled Shift Date* Date Format: MM slash DD slash YYYY Scheduled Shift Start* : HH MM AM PM Scheduled Shift End* : HH MM AM PM Total Hours of CA Sick Pay Requesting* Date of Missing Hours* Date Format: MM slash DD slash YYYY Shift Start Time* : HH MM AM PM Time Out for First Rest Break : HH MM AM PM Time In from First Rest Break : HH MM AM PM Time Out for Meal Break : HH MM AM PM Time In from Meal Break : HH MM AM PM Time Out for Second Rest Break : HH MM AM PM Time In from Second Rest Break : HH MM AM PM Shift End Time* : HH MM AM PM Total Number of Regular Hours*Total Number of OT Hours*Reason for Missing Hours* Date* Date Format: MM slash DD slash YYYY Reason for Mileage*TrainingIngredient TransferOtherExplain Reason*Starting Location*Ending Location*Number of Miles* Reason for Uniform Request*Type of Uniform Requesting*Male CrewFemale CrewMale ManagerFemale ManagerMaintenanceAccessoriesCrew UniformsShirt Size*Pick OneXSSMLXL2XL3XL4XL5XLQuantity*Manager UniformsPolo Shirt SizePick OneXSSMLXL2XL3XL4XL5XLQuantityPant Type Tailored Pant Jean JeansWaist Size2022242628303234363840424446485052JeansWaist Size0246810121416182022242628303234QuantityTailored PantWaist Size2022242628303234363840424446485052Tailored PantWaist Size0246810121416182022242628303234Pant Inseam303234QuantityManager Shoe TypeMale RegularMale WideFemale RegularFemale WideShoe SizeMaintenance UniformsShirt SizePick OneXSSMLXL2XL3XL4XL5XLQuantityOuterwear Jacket Sweatshirt JeansWaist Size2022242628303234363840424446485052QuantityShoe SizeShoe TypeMale RegularMale WideFemale RegularFemale WideUniform AccessoriesNumber of HatsNumber of VisorsNumber of NametagsNumber of Belts Comments or Suggestions:*Your comments and concerns are important to us. Please use the below boxes to provide additional details so that we know where to look or investigate to address your concerns. Thank you for coming to us!Additional Details:City of Concern: Stockton Lodi Manteca Tracy Galt Sacramento Elk Grove Lathrop Martell Can we contact you to further investigate? First Last Please enter your availability for each day. Please note, schedules are based on the needs of the business, hours are never guaranteed, and your employment remains “at will,” meaning that either you or the Company can end the employment relationship for any reason at any time. MondayTuesdayWednesdayThursdayFridaySaturdaySundayNumber of Hours per WeekSignature*Terms of Service I agree to the Terms of Service