Section 4: Certification and Agreement
I hereby certify that the information provided in and with this Application is true and
accurate. I am aware that any statements made herein which are willfully false are
subject to penalty under applicable state and federal laws. Submission of this
Application does not entitle me to any claim against Wingstop Charities or its Team
Member Assistance Fund, but constitutes an application for assistance.
I also understand that by signing below, I hereby authorize representatives of Wingstop
Charities to obtain necessary information to assist Wingstop Charities with the review
of this Application, including information regarding my salary, benefits, employment
status, insurance coverage and other information relevant to this Application. I hereby
waive any privacy rights granted to me under the Health Insurance Portability and
Accountability Act of 1996 relative to the release of otherwise protected information
regarding my health that may be relevant to this Application.
I am making this Certification and Agreement voluntarily and my consent to information
exchange and waiver of privacy rights will expire automatically on the first to occur of
the disclosure of the requested information or one hundred eighty (180) days after the
I have read this Certification and Agreement and understand that there may be significant
consequences for providing false information on this Application.