Run Casino Dealer Tip Pooling Election Form — Free

Dealer Information

Full Legal Name (required)

Employee ID / Badge Number (required)

Department / Pit (required)

If 'Other', please specify department

Primary Shift (required)

Date of Hire (required)

Your original hire date as a dealer at this property.

Election Effective Date (required)

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 (required)

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 (required)

Select the method by which pooled tips are distributed.

Distribution Frequency (required)

Employer / Management Participation Disclosure (required)

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 (required)

An HR representative will contact you to confirm the meeting. Your election will be held pending resolution.

Election Decision

Tip Pool Election (required)

Reason for Requesting Review

Are you currently represented by a union or collective bargaining agreement? (required)

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 (required)

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.

Yes No N/A

No Employer Retention Acknowledgment (required)

I understand that the employer, managers, and supervisors do not retain any portion of the tip pool.

Yes No N/A

Participation Terms Acknowledgment (required)

I understand the participation terms applicable to my position as described in Section 3 of this form.

Yes No N/A

Records Retention Consent (required)

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.

Yes No N/A

Right to Copy (required)

I understand that I am entitled to a copy of this completed and countersigned form.

Yes No N/A

Additional Comments or Questions (Optional)

Dealer Signature

Dealer Signature (required)

Draw or apply your electronic signature to confirm your election.

Date Signed (required)

Today's date.

Signature Attestation (required)

Yes No N/A

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Run: Casino Dealer Tip Pooling Election Form

Dealer Information

Tip Pool Arrangement Details

Election Decision

Acknowledgments & Consent

Dealer Signature

Get your results