EMPLOYEE REQUEST Please complete your request below. Step 1 of 19 5% Request Type* Anonymous Suggestion/Comment Box Availability Change Day of Rest Acknowledgement and Waiver eID Help Leave of Absence (LOA) Request Location Change Request Mileage Tracking Missing Hours Request Paid Time Off Request Payroll Help Personal Information Change Pregnancy Notification Resignation Form Time Off Request (not LOA) Uniform Request Voluntary Go Home Notice Work Permit Status Change Work Order Request If you are looking to place a request asking about your W2, all W2s will be available in your iSolved Employee Self Service Portal by the IRS deadline of January 31st. Name First Last Not requiredEmail Not requiredPhoneNot required Today's Date* MM slash DD slash YYYY Request Submitted By If 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 #12264Martell #13329Westley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681GSRG #1000GSRG Type* Office Board Operations Maintenance Other Consent* I certify that the information submitted is true and correct to the best of my knowledge. First Day of Requested Leave* MM slash DD slash YYYY Last Day of Requested Leave* 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 Leave Personal 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 Benefits 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 UploadMax. file size: 200 MB.Are you traveling during your leave?* Yes No Are you traveling out of state?* Yes No Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* Reset signature Signature locked. Reset to sign again Type of Permit Update* Permit Renewal Permit Change Current Work Permit Expiration Date* MM slash DD slash YYYY New Work Permit Expiration Date* MM slash DD slash YYYY New Work Permit*Max. file size: 250 MB.School/School District Providing Work Permit* Type of Work Permit* Standard Work 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 #12264Martell #13329Westley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681GSRG #1000Reasoning for Request* Employee Resignation Please complete the below resignation form for your Employee Record.Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Last Day You Plan to Work* MM slash DD slash YYYY Reason for Resignation* Another Job Child Care Medical Permanent Disability Relocation Retirement Other Location of Other Job Reason for Relocation Moving School Family Location of Relocation "Other" Reason*Comments for Resignation LetterSignature* Reset signature Signature locked. Reset to sign again Shift Date* MM slash DD slash YYYY Scheduled Shift Start Time* : Hours Minutes AM PM AM/PM Scheduled Shift End Time* : Hours Minutes AM PM AM/PM Leaving Time* : Hours Minutes AM PM AM/PM Reason for Leaving Early*Temperature When LeavingI left my shift early voluntarily:* Reset signature Signature locked. Reset to sign again What help do you need?Do you also need to update your personal information?* Yes No Time Off Request: WFM RestaurantYour restaurant is now scheduling using LIFELENZ or harri. Please refer to the employee app for your restaurant to submit a time off request. You do not need to download the employee app to your own device, you may choose to use the iPad at the restaurant to log in and submit your request.Time Off RequestTime 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 are 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?* Yes No Requested Leave Start Date* MM slash DD slash YYYY Requested Leave End Date* MM slash DD slash YYYY I agree to return to work on...* MM slash DD slash YYYY Reason for Requested Time OffSignature* Reset signature Signature locked. Reset to sign again Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Estimated Due Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If modifications are needed, please list:*Shoe Size*Shoe Type* Regular Wide Upload a Doctor's NoteMax. file size: 300 MB. Equipment Type Issue:*Troubleshooting Steps Previously Completed:*Error CodesPicture of Equipment or ErrorMax. file size: 300 MB.Is this an OTP/POS technology work order?* Yes No If this is for POS keys or Digital Menu Boards please complete a Task Request at goldenstatemcd.com/tasks to be sure the request is routed to the correct person.Is this construction related?* Yes No Not Sure Construction related means anything that has to do with the physical building, plumbing/electrical, etc. Equipment is not construction related. HiddenPaid Time Off Request Type* Accrued CA Sick Leave 2022 COVID-19 Supplemental Paid Sick Leave Signature* Reset signature Signature locked. Reset to sign again Accrued CA Sick LeaveAny late requests will be reviewed on the next pay period following request. NOTE: Completing this form does not specifically qualify as notifying your restaurant of your time off, please call the restaurant to notify the team that you will be absent. I am requesting to use accrued paid sick leave available under California law for the following reason:* for diagnosis, care or treatment of an existing medical condition for preventive care* as a victim of domestic violence, sexual assault or stalking and time off is needed*** *Preventative care may include self-quarantine due to potential or actual exposure to COVID-19 or travel to a high-risk area. **For purposes of this policy, "eligible family members" include a: Spouse; Biological, adopted or foster child, stepchild, legal ward or a child to whom the employee stands in loco parentis (in place of a parent); Biological, adoptive or foster parent, stepparent, or legal guardian of an employee or the employee’s spouse or registered domestic partner or a person who stood in loco parentis when the employee was a minor child; Sibling; Grandparent or grandchild; and Registered domestic partner (as defined by state or local law), as well as the child or parent of a registered domestic partner. The definition of "child" applies regardless of a child's age or dependency status. ***Needed to: Obtain or attempt to obtain any relief (e.g., a temporary restraining order, restraining order or other injunctive relief) to help ensure the health, safety or welfare of the victim or the victim’s child; Seek medical attention for injuries caused by domestic violence, sexual assault or stalking; Obtain services from a domestic violence shelter, program or rape crisis center as a result of domestic violence, sexual assault or stalking; Obtain psychological counseling related to an experience of domestic violence, sexual assault or stalking; or Participate in safety planning and take other actions to increase safety from future domestic violence, sexual, assault, or stalking, including temporary or permanent relocation.Scheduled Shift Date* MM slash DD slash YYYY Scheduled Shift Start* : Hours Minutes AM PM AM/PM Scheduled Shift End* : Hours Minutes AM PM AM/PM HiddenTotal Hours of CA Sick Pay Requesting*Hidden2022 COVID-19 Supplemental Paid Sick LeaveHiddenWhich type of 2022 COVID-19 Supplemental Paid Sick Leave are you requesting?* I am unable to work due to caring for myself, caring for a qualified family member, or vaccine-related reason To care for myself or a qualified family member that has tested positive for COVID-19 Select all that applyHiddenI am requesting to use 2022 COVID-19 Supplemental Paid Sick Leave available under California law for the following reason:* Caring for Myself Caring for a Qualified Family Member* Vaccine Related *A family member is defined as a child**, parent***, spouse, registered domestic partner, grandparent, grandchild, or sibling. **A child can include a biological, adopted, or foster child, a step-child, legal ward, or child to whom the employee stands in loco parentis. ***A parent includes a biological, adoptive, or foster parent, step-parent, or legal guardian of the employee or the employee's spouse or registered domestic partner or person who stood in loco parentis when the employee was a minor child.HiddenPlease select which is applicable:* I am subject to a quarantine or isolation period related to COVID-19 I have been advised by a healthcare provider to quarantine due to COVID-19 I am experiencing symptoms of COVID-19 AND seeking a medical diagnosis NOTE: The quarantine or isolation period related to COVID-19 is the period defined by an order or guidelines of the California Department of Public Health, the federal Centers for Disease Control and Prevention, or a local health officer with jurisdiction over the workplace.HiddenPlease select which is applicable:* I am caring for a family member who is subject to a quarantine or isolation period related to COVID-19 I caring for a family member who has been advised by a healthcare provider to quarantine due to COVID-19 I caring for a a child whose school or place of care is closed or unavailable due to COVID-19 on the premises NOTE: The quarantine or isolation period related to COVID-19 is the period defined by an order or guidelines of the California Department of Public Health, the federal Centers for Disease Control and Prevention, or a local health officer with jurisdiction over the workplace.HiddenPlease select which is applicable:* Myself or a qualified family member is attending a vaccine appointment I cannot work due to vaccine-related symptoms for myself or a qualified family member HiddenHours of 2022 COVID-19 Supplemental Paid Sick Leave Requesting (B1)*Note: The total hours you request may not be what you are entitled to.HiddenHave you or a Qualified Family Member* tested positive for COVID-19?* Yes No *A family member is defined as a child**, parent***, spouse, registered domestic partner, grandparent, grandchild, or sibling. **A child can include a biological, adopted, or foster child, a step-child, legal ward, or child to whom the employee stands in loco parentis. ***A parent includes a biological, adoptive, or foster parent, step-parent, or legal guardian of the employee or the employee's spouse or registered domestic partner or person who stood in loco parentis when the employee was a minor child.HiddenPlease upload proof of a positive test:*Max. file size: 300 MB.HiddenHours of 2022 COVID-19 Supplemental Paid Sick Leave Requesting (B2)*Note: The total hours you request may not be what you are entitled to.HiddenDid you use CA Sick Pay or PTO between January 1, 2022 and February 18, 2022?* Yes No HiddenWould you like to have the CA Sick Pay/PTO hours that were used between 1/1/22 - 2/18/22 for COVID leave credited back to your available balance?* Yes No The new law is explicit in stating that if an employee was fully paid, but leave for the absence was deducted from another leave bank that the employer provides, the employee may request that leave be restored and the deduction be made in a corresponding amount from the employee’s 2022 SPSL leave bank. The decision to restore used time is the employee’s decision.HiddenPlease provide Medical Certification that you or your qualified family member required more time to recover from side effects:*Max. file size: 300 MB.HiddenSpecific DATES of 2022 COVID-19 Supplemental Paid Sick Leave Requesting*HiddenPlease upload verification of your vaccination appointmentMax. file size: 300 MB.Please upload a doctor's noteMax. file size: 300 MB. Date of Missing Hours* MM slash DD slash YYYY Shift Start Time* : Hours Minutes AM PM AM/PM Time Out for First Rest Break : Hours Minutes AM PM AM/PM Time In from First Rest Break : Hours Minutes AM PM AM/PM Time Out for Meal Break : Hours Minutes AM PM AM/PM Time In from Meal Break : Hours Minutes AM PM AM/PM Time Out for Second Rest Break : Hours Minutes AM PM AM/PM Time In from Second Rest Break : Hours Minutes AM PM AM/PM Shift End Time* : Hours Minutes AM PM AM/PM Total Number of Regular Hours*Total Number of OT Hours*Reason for Missing Hours* Date* 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 Crew Female Crew Male Manager Female Manager Maintenance Accessories Crew UniformsShirt Size*Pick OneXSSMLXL2XL3XL4XL5XLQuantity*Manager UniformsPolo Shirt SizePick OneXSSMLXL2XL3XL4XL5XLQuantityPant Type Tailored Pant Jean JeansWaist Size2022242628303234363840424446485052JeansWaist Size02468101214161820QuantityTailored PantWaist Size2022242628303234363840424446485052Tailored PantWaist Size02468101214161820Pant Inseam303234QuantityManager Shoe Type Male Regular Male Wide Female Regular Female Wide Shoe SizeMaintenance UniformsShirt SizePick OneXSSMLXL2XL3XL4XL5XLQuantityOuterwear Jacket Sweatshirt JeansWaist Size2022242628303234363840424446485052QuantityShoe SizeShoe Type Male Regular Male Wide Female Regular Female Wide Uniform AccessoriesNumber of HatsNumber of VisorsNumber of Nametags 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 Restaurant of Concern: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 #12264Martell #13329Westley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681GSRG #1000Can we contact you to further investigate? First Last Availability Change: WFM RestaurantYour restaurant is now scheduling using LIFELENZ or harri. Please refer to the employee app for your restaurant to submit an availability change request. You do not need to download the employee app to your own device, you may choose to use the iPad at the restaurant to log in and submit your request.Availability ChangePlease 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. If the restaurant schedule is currently posted and in progress, your new availability will be taken into consideration when the next schedule is created. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Number of Hours per WeekSignature* Reset signature Signature locked. Reset to sign again Terms of Service I agree to the Terms of Service Acknowledgement*I understand, as an employee of the Company, I am generally entitled to one day of rest for each workweek. The workweek begins at 4:00am on Wednesday and ends at 3:59am on the next Wednesday. I understandAcknowledgement*I understand that the Company cannot require, encourage, or induce me to go without a day of rest in the workweek. However, I can voluntarily choose not to take a day of rest. I understandDate of This Workweek*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For the workweek above, I have worked or am scheduled to work six days.* I have been offered the option to work a seventh day this workweek. I am requesting to work a seventh day this workweek. Acknowledgement*I acknowledge that I have voluntarily chosen to work on the seventh day of the current workweek and to waive my entitlement to a day of rest. I want to work on this additional day in order to receive additional wages, including any applicable overtime. I understandAcknowledgement*I was not forced, coerced or in any other way pressured or encouraged to work this seventh day. I could choose not to work on the seventh day and would not suffer any retaliation or other adverse work consequences for deciding not to work on this day. I understandEmployee Signature* Reset signature Signature locked. Reset to sign again