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'LANA.% 1 1.1 Sunday <br /> EMPLOYMENT SERVICES - <br /> P.O. Box 71250 • Eugene, OR 97401 Monday __ <br /> EMPLOYEE <br /> Tuesday .. - I certify that the hours shown represent my total hours worked during the <br /> PLEASE PRINT - week, and that they were properly verified by the client or by an authorized <br /> E L YEE NAME - representative. Also, any work related injuries were reported to Selectemp <br /> at the time of injury. See reverse for further information. <br /> k. C L 4A...Ci e • \ Wednesday <br /> SOCIAL SECURITY NUMBER • X °G "` �.,._ <br /> Signature of Employee <br /> Thursday <br /> COMPANY NAME CLIENT <br /> We realize that to transfer one of Selectemp's employees to our <br /> P -y , payroll requires a settlement Se e reverse for further information. I <br /> Friday t L.. , r , i 9 IIC hereby cart' that the above hours �Je correct. <br /> WEEK ENDING DATE y P � ' <br /> 1, 7 { Saturday X ( /�/ <br /> / / • Sign e o uperwsor <br /> ❑ ASSIGNMENT COMPLETED OrffErtciNING f1tING NEXT WEEK TOTAL TOTAL ! ( /�'A, / 1 /1 <br /> 2 <br /> Hours to nearest quarter hour. 7 S j <br /> Title 1' y', J 1 Date <br /> _ <br /> HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? �• J ! <br /> ❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br /> 10 <br /> CUSTOMER COPY <br />