Employee Tip Pool Acknowledgment

EMPLOYEE TIP POOL ACKNOWLEDGMENT

Personal Information

Position Information

Start Date:   Hourly Rate/Salary:

Employment History (Most Recent Two Employers)

Education

Professional References

Reference 1 - Name:   Phone:   Email:

Relationship:

Reference 2 - Name:   Phone:   Email:

Relationship:

Reference 3 - Name:   Phone:   Email:

Relationship:

Tip Pool Policy — Terms and Acknowledgment

Definitions: For purposes of this acknowledgment, "Tip" means a voluntary transfer of money by a patron to an employee in recognition of service; "Tip Pool" means a collection of Tips contributed by employees and redistributed to Eligible Employees by the Employer; "Eligible Employees" means employees designated by the Employer as covered by the Tip Pool policy. The Employer's designation of Eligible Employees will conform to applicable law.

Participation and Allocation: I acknowledge that the Employer maintains a Tip Pool. I understand and agree that Tips I receive may be required to be contributed to the Tip Pool and redistributed to Eligible Employees in accordance with established allocation practices. Tips placed into the Tip Pool will be redistributed periodically and shall generally be allocated based on documented hours worked in tip-eligible positions or an alternate equitable point-based system as determined by Employer. The specific method of allocation is at the Employer's discretion so long as it complies with law.

Recordkeeping and Distribution Frequency: Employer will maintain records of Tip Pool contributions and distributions. Distributions will occur no less frequently than monthly unless otherwise required by law. I am entitled to request information about the calculation of my share of pooled Tips and to receive explanations in accordance with applicable law.

Prohibitions and Deductions: Employer will not retain Tips for any purpose except as permitted by applicable law. Deductions from Tips for costs of business (other than those expressly permitted by law) are prohibited. Where a service charge is imposed by the Employer and not designated as a Tip, it will be treated separately from pooled Tips.

Employer Rights and Policy Changes: Employer reserves the right to modify the composition of the Tip Pool, method of distribution, and Eligible Employees by written notice to employees. Changes will be made prospectively and in compliance with applicable law.

Tax Reporting: I understand that Tips are taxable income and that I am responsible for reporting Tip income on my tax returns as required by law. Employer will report Tip income in accordance with applicable law.

Confidentiality and Audits: Records related to Tip Pool calculations are business records of the Employer. The Employer may audit Tip Pool records and adjust distributions if errors are discovered. Unauthorized disclosure of payroll or Tip Pool records may be subject to disciplinary action.

Disciplinary Action: Refusal to comply with a lawful Tip Pool policy, falsification of Tip records, or other intentional misconduct related to Tips may result in progressive discipline up to and including termination of employment.

Acknowledgments and Authorizations

By checking the box below I certify that I have received, read, and understand the Employer's Tip Pool Policy and agree to abide by its terms as a condition of my employment.

  I acknowledge receipt of the Tip Pool Policy and agree to its terms.

  I consent to the collection and redistribution of Tips through the Employer's Tip Pool as described above.

Background and Reference Authorization: I hereby authorize the Employer to contact prior employers and professional references listed herein for the purpose of verifying employment history and references. I authorize the release of information necessary for such verification and understand this authorization is a continuing authorization for employment-related inquiries.

At-Will Employment: I understand that my employment is at-will and that nothing in this Tip Pool Acknowledgment alters the at-will nature of my employment, unless a written agreement signed by an authorized representative of the Employer explicitly states otherwise.

Equal Employment Opportunity: Employer is an equal opportunity employer. Employment decisions are made without regard to protected characteristic and in accordance with applicable law.

Applicant / Employee Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that falsification or omission of material information may result in disciplinary action, up to and including termination. I authorize the Employer to verify any and all information provided on this form.

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