Employee Request - Golden State Restaurant Group

Request Type*
- Payroll Help
- 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
- CA Sick Pay Request
- Resignation Form
- Missing Hours Request
- Uniform Request
- Mileage Tracking
Name
First Last
Not required
Email

Not required
Phone
Not required

Request Submitted By*
Employee Name*
First Last
Email for Confirmation and Response*
Employee Time Card Number*
Last 4 Employee SSN*
Restaurant*
GSRG Type*
- Office
- Operations
- Maintenance

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 Leave
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
Doctor's Note Upload
Address*
Street Address City 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 Renewal
- Permit Change
Current 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*
- Standard
- Work Experience

Disclosure
This is a request to change restaurant locations. Your request will be sent to the appropriate individuals to determine next steps.
Requested New Restaurant*
Reasoning for Request*

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

: HH

MM
Scheduled Shift End Time*

: HH

MM
Leaving Time*

: HH

MM
Reason for Leaving Early*
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
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.
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.
Are you a Restaurant Manager?*
- Yes
- No
Requested 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
Signature*

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

Please provide your notification:*
Shoe Size*
Shoe Type*
- Regular
- Wide

Equipment Type
Issue:*
Troubleshooting Steps Previously Completed:*
Error Codes
Picture of Equipment or Error
Is this construction related?*
- Yes
- No
- Not Sure

Any late requests will be reviewed on the next pay period following request.
Scheduled Shift Date*
Date Format: MM slash DD slash YYYY
Scheduled Shift Start*

: HH

MM
Scheduled Shift End*

: HH

MM
Total Hours of CA Sick Pay Requesting*

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

: HH

MM
Time Out for First Rest Break

: HH

MM
Time In from First Rest Break

: HH

MM
Time Out for Meal Break

: HH

MM
Time In from Meal Break

: HH

MM
Time Out for Second Rest Break

: HH

MM
Time In from Second Rest Break

: HH

MM
Shift End Time*

: HH

MM
Reason for Missing Hours*

Date*
Date Format: 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
Can we contact you to further investigate?
First Last

Please complete your request below.

Step 1 of 17

Crew Uniforms

Manager Uniforms

Maintenance Uniforms

Uniform Accessories