Please fill in all fields marked with a *
	FIRST NAME	*
	LAST NAME	*
	ADDRESS	*
	CITY	*
	STATE	*
	ZIP	*
	PHONE	*
	EMAIL
	NAME OF RESTAURANT	*
	TITLE
	DATES OF EMPLOYMENT
	HOURLY WAGE
	AMOUNT OF YOUR TIP POOL CONTRIBUTION IF ANY
	WHO SHARED IN THE TIP POOL
	ADDITIONAL INFORMATION