Please complete your request below.

I certify that the information submitted is true and correct to the best of my knowledge.

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

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

This is a request to change restaurant locations. Your request will be sent to the appropriate individuals to determine next steps.

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.

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.