Employee Request - Golden State Restaurant Group

Request Type*
- Anonymous Suggestion/Comment Box
- Availability Change
- Day of Rest Acknowledgement and Waiver
- eID Help
- Elite Paycard Agreement
- 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 required
Email

Not required
Phone
Not 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*
GSRG Type*
- Office
- Board
- Operations
- Maintenance
- Other
Consent*
I certify that the information submitted is true and correct to the best of my knowledge.

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*
Reasoning for Request*

Shift Date*
MM slash DD slash YYYY
Scheduled Shift Start Time*

: Hours

Minutes

AM/PM
Scheduled Shift End Time*

: Hours

Minutes

AM/PM
Leaving Time*

: Hours

Minutes

AM/PM
Reason for Leaving Early*
Temperature When Leaving
I left my shift early voluntarily:*

What help do you need?
Do you also need to update your personal information?*
- Yes
- No

Time Off Request: WFM Restaurant
Your 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 Request
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 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 Off
Signature*

Address
Street Address Address Line 2 City State ZIP Code
Phone
Email

Estimated Due Date*
If modifications are needed, please list:*
Shoe Size*
Shoe Type*
- Regular
- Wide
Upload a Doctor's Note
Max. file size: 300 MB.

Equipment Type
Issue:*
Troubleshooting Steps Previously Completed:*
Error Codes
Picture of Equipment or Error
Max. 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.

Date of Missing Hours*
MM slash DD slash YYYY
Shift Start Time*

: Hours

Minutes

AM/PM
Time Out for First Rest Break

: Hours

Minutes

AM/PM
Time In from First Rest Break

: Hours

Minutes

AM/PM
Time Out for Meal Break

: Hours

Minutes

AM/PM
Time In from Meal Break

: Hours

Minutes

AM/PM
Time Out for Second Rest Break

: Hours

Minutes

AM/PM
Time In from Second Rest Break

: Hours

Minutes

AM/PM
Shift End Time*

: Hours

Minutes

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*
Explain Reason*
Starting Location*
Ending Location*
Number of Miles*

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:
Can we contact you to further investigate?
First Last

Availability Change: WFM Restaurant
Your 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 Change
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. 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 Week
Signature*
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 understand
Acknowledgement*
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 understand
Date of This Workweek*
For 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 understand
Acknowledgement*
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 understand
Employee Signature*

10 Digit Paycard Number*
PaychekPLUS! Elite Visa Payroll Card Enrollment*
Consent to Payroll Card Account
I hereby designate MetaBank as my financial institution to accept the direct deposit of my wages from my employer into an account at MetaBank. I choose to receive a Visa Payroll Card issued on my behalf by MetaBank for the purpose of accessing my wages from my Payroll Card account. I acknowledge that third parties other than MetaBank may impose fees and charges in connection with the use of the Visa Payroll Card; however, I understand that I may choose one of several transactions each pay period, which are outlined in the Cardholder Terms and Conditions, by which I can withdraw my entire net pay without the payment of a fee.
Your Prepaid Card Account and associated direct deposit account number cannot be used for preauthorized direct debits from merchants or from utility or Internet service providers. If presented for payment, these preauthorized direct debits will be declined and your payment to the merchant or provider will not be processed. The bank routing number and direct deposit account number are for the purpose of initiating direct deposits to your Prepaid Card Account only. You are not authorized to provide this bank routing number and direct deposit account number to anyone other than your employer or payer.
Direct deposit capability is subject to payer’s support of this feature. Check with your payer to find out when the direct deposit of funds will start. Funds availability is subject to timing of payer’s funding.

Important Information about Procedures for Creating a Payroll Card Account
To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for me: When I apply for a Payroll Card, I will be asked for my name, address, date of birth, and other information that will allow you to reasonably identify me. I may also be asked to see my driver’s license or other identifying documents at any time.

Use of Payroll Card
I may withdraw funds or make purchases through use of the Visa Payroll Card issued by MetaBank. The features and rules of the Payroll Card and applicable fees are described in the Cardholder Agreement. By signing below, I acknowledge receipt of the Cardholder Agreement and agree to abide by all terms and provisions contained therein.

Ownership of Funds
Funds will be electronically deposited into a deposit account on the books of MetaBank, for my benefit. I may withdraw funds by using the Visa Payroll Card. I may withdraw only the amount of my separate amount deposited pursuant to this Agreement in such deposit account.

< b> FDIC Insurance
MetaBank is a member of the Federal Deposit Insurance Corporation (“FDIC”): All value on the Card is shown in United States dollars. Your deposits are FDIC insured up to $250,000.

Record keeping and Customer Service
By signing this Acceptance Form, I agree that FSV Payment Systems, Inc. (“FSV”) will maintain the records related to the Payroll Card and the Visa Payroll Card account balance as an Independent Sales Organization of MetaBank and will provide customer service for such Visa Payroll Card.
- I declare the forgoing to be true and complete to the best of my knowledge. I authorize my employer to deposit my wages each payday directly into my Visa Payroll Card account. This authority remains in effect until I have given written notice to my employer that I want the agreement terminated. If funds to which I am not entitled are deposited into my Visa Payroll Card account, I authorize my employer to direct MetaBank to return said funds. I also understand that it is my responsibility to verify deposits prior to any transactions against the card balance.

Please complete your request below.

Step 1 of 20

Time Off Request: WFM Restaurant

Time Off Request

Accrued CA Sick Leave

2022 COVID-19 Supplemental Paid Sick Leave

Crew Uniforms

Manager Uniforms

Maintenance Uniforms

Uniform Accessories

Availability Change: WFM Restaurant

Availability Change