Casino Dealer Tip Pooling Election Form

A form documenting a casino dealer's formal election or acknowledgment of the tip pooling (toke) arrangement, including pool participation terms, distribution method, and signed consent in compliance with FLSA Section 3(m)(2)(B) tip pool disclosure requirements.

Dealer Information

• Full Legal Name
• Employee ID / Badge Number
• Department / Pit
• If 'Other', please specify department
• Primary Shift
• Date of Hire
  Your original hire date as a dealer at this property.
• Election Effective Date
  The date from which this tip pool election takes effect. Typically the first day of the next pay period.

Tip Pool Arrangement Details

• Tip Pool Type
  Select the tip pool arrangement that applies to your position. Under FLSA §3(m)(2)(B), tip pools may only include employees who customarily and regularly receive tips.
• Distribution Method
  Select the method by which pooled tips are distributed.
• Distribution Frequency
• Employer / Management Participation Disclosure
  FLSA §3(m)(2)(B) prohibits employers, managers, and supervisors from participating in a tip pool. Confirm the following is accurate for this property.
• Preferred Date/Time for HR Meeting
  An HR representative will contact you to confirm the meeting. Your election will be held pending resolution.

Election Decision

• Tip Pool Election
• Reason for Requesting Review
• Are you currently represented by a union or collective bargaining agreement?
  If yes, tip pool terms may be governed by your CBA. HR will coordinate with your union representative.
• Union / CBA Name

Acknowledgments & Consent

• FLSA Disclosure Acknowledgment
  I acknowledge that I have received written disclosure of the tip pooling arrangement as required by the Fair Labor Standards Act (FLSA) Section 3(m)(2)(B) and applicable state wage-and-hour law.
• No Employer Retention Acknowledgment
  I understand that the employer, managers, and supervisors do not retain any portion of the tip pool.
• Participation Terms Acknowledgment
  I understand the participation terms applicable to my position as described in Section 3 of this form.
• Records Retention Consent
  I consent to this form being retained in my personnel file for a minimum of 3 years per FLSA recordkeeping requirements (29 CFR Part 516) and applicable state law.
• Right to Copy
  I understand that I am entitled to a copy of this completed and countersigned form.
• Additional Comments or Questions (Optional)

Dealer Signature

• Dealer Signature
  Draw or apply your electronic signature to confirm your election.
• Date Signed
  Today's date.
• Signature Attestation