EMPLOYEE REQUEST Please complete your request below. Step 1 of 17 5% Request Type* Accommodation or Work Restriction Anonymous Suggestion/Comment Box Day of Rest Acknowledgement and Waiver Direct Deposit Change eID Help Leave of Absence (LOA) Request Location Change Request Mileage Tracking Missing Hours Request Paid Time Off Request Payroll Help Pregnancy Notification Resignation Form Uniform Request Voluntary Go Home Notice Work Order Request Name First Last Not requiredEmail Not requiredPhoneNot requiredWe encourage your open comments and respect your request for anonymity, please note it is easier to address your concerns if we have more detail: the restaurant, your position, or your contact information. Thank you! Today's Date* MM slash DD slash YYYY Request Submitted ByIf submitting for yourself, there is no need to complete this field.Employee Name* First Last Email for Confirmation and Response* If you are requesting a direct deposit change be sure that you can access the email address you enter above. You will be required to reply to an email with your confirmation that you would like the change to be put in place for the next payroll.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 #36681Reynolds Ranch #40627Weston Ranch #40735GSRG #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* I agree and understand the Personal Leave Notice FMLA, PDL, or CFRA Leave Notice* I agree and understand the FMLA, PDL, or CFRA Leave Notice Doctor's Note UploadMax. file size: 100 MB. Are you traveling during your leave?* 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*Are you a Restaurant Manager?* Yes No Comments*Employee Signature* Location Change Disclosure* 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 #36681Reynolds Ranch #40627Weston Ranch $40735GSRG #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 If enrolled in wagestream through Harri Pay, do you consent to having your final wages paid through wagestream? Yes No I am not enrolled in wagestream/Harri Pay Reason for Resignation* Another Job Child Care Medical Permanent Disability Relocation Retirement Location of Other JobReason for Relocation Moving School Family Location of RelocationSignature* 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:* What help do you need? Our payroll company has strongly advised against using third-party financial platforms such as BankCorp, Chime, and PayPal due to a rise in fraudulent activity, delayed/redirected deposits, and compromised account access involving these services- all of which have resulted in lost wages that cannot be recovered. The payroll company urges you to use a secure, traditional banking institution for direct deposit.Bank Name*Routing Number*Account Number*Deposit Amount* Deposit Entire Net Amount Deposit Partial Net $ Deposit Partial Net % Deposit Partial Net % Amount*Please enter a number from 0 to 100.Deposit Partial Net $ Amount*Please enter a number greater than or equal to 0.ACH Consent* I agreeI hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating credit entries to my account(s) at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my account(s). In the event that Company deposits funds erroneously into my account(s), I authorize Company to debit my account(s) for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until Company and Bank have received written notice from me of its termination in such time and such manner as to afford Company and Bank reasonable opportunity to act on it. Estimated Due Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If modifications are needed, please list:Shoe Size*Shoe Type* Regular Wide Upload a Doctor's NoteMax. file size: 100 MB. Equipment TypeIssue:*Troubleshooting Steps Previously Completed:*Error CodesPicture of Equipment or ErrorMax. file size: 100 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. Select your Job Title Crew Crew Trainer Crew Leader Maintenance Person Facilities Manager Shift Manager Second Assistant First Assistant RMOTF Restaurant Manager Paid Time Off Request Type* Accrued CA Sick Leave Paid Time Off Any 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 or use TeamLive.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*** as a victim of any crime and is appearing in court as a witness to comply with a subpoena or other court order**** is serving on an inquest jury or trial jury**** *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. ****For this covered use only, the law defines “victim” as a person against whom a violent felony, serious felony, and/or felony theft or embezzlement is committed. Additionally, it includes a person who suffers direct or threatened physical, psychological, or financial harm due to the commission or attempted commission of the following crimes or delinquent acts: vehicular manslaughter while intoxicated; felony child abuse likely to produce great bodily harm or a death; assault resulting in the death of a child under eight years old; felony domestic violence; felony physical abuse of an elder or dependent adult; felony stalking; solicitation for murder; a serious felony; hit-and-run causing death or injury; felony driving under the influence causing injury; sexual assault.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 Total Hours of CA Sick Pay Requesting*Total Hours of PTO Pay Requesting* 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 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!Comments or Suggestions:*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 #36681Reynolds Ranch #40627Weston Ranch #40735GSRG #1000Can we contact you to further investigate? First Last We encourage your open comments and respect your request for anonymity, please note it is easier to address your concerns if we have more details.PhoneEmail 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*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For 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* Expected Accommodation or Work Restriction Start Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Expected Accommodation or Work Restriction End DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Consent* I understand that I will need to go through the request process in Harri for approval.Once this request is submitted, the third party benefits provider will work with you through Harri to determine the appropriate accommodation or work restriction you require. Please check your email for those documents to complete the process.