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<br />r EM-0L.OYMENT SERVI(ES~ <br />PO. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />EMPLOYEE NAME <br />1 '- t.11iY. -~ <br />SOCIAL SECURITY NUMBER C <br />COMPANY NAME l/ C- I <br />C-<.J~ ~ <br />~' i <br />i. , <br />WEEK ENDINGDATE - <br />... <br />^ASSIGNMENT COMPLETED ya RETURNING NE%T WEEK <br />HAVE VOU HAD AN ON THE J081NJURV THIS WEEK? <br />^ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />U NO <br />LUNCH HOUR <br />Sunday <br />Monday ~' -- "t p " <br />... LC'x J <br />rr <br />Wetlnestlay ~~(1.: ~~ <br />_ F,-• 'S <br />rrr Cam. <br />$aWrday <br />Hours to ne9resl quarter hour. <br />HOURS REG.HOURS O.T. HOURS <br />EMPLOYEE' <br />I ceftily Ihel the hours shown represent my IaGldaurs wdrketl tlutlng Ne <br />' 'weak, end that Aey were prppary verHietl by.ihe diem or oleo authprizetl <br />repreeenlallve. Also, any woB related injuiias were reported to $eledtemp <br />al IM1e lime pi Injury See reverse br Wrther inlormetioa. <br />.. n . <br />X iT.;~ <br />Sigriatbreal Emddyee <br /> <br />E~MDLOYMENI SERVICES ' <br />PO. BDZ 77250 • Eugene, OR 97401 Monday <br />PI FASF PAINT <br />_ EMPLOYEE NAME <br />SOCIAL SECURITY NU~vIBER <br />~/f; /i <br />COMPANY NAME <br />i .-, <br />~- l_. ~ <br />~, JOBSITE NAME AND/OR POu <br />WEEK ENDING DATE <br />^ ASSIGNMENT COMPLETED ~ RETURNING NE%T WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^ YES IF YES;.NOTIEV SELECTEMPIMMEDIATELY: <br />®. NO <br />S C P <br />EMD LOYMENT SE RYI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />Tuesday <br />Wedhestlay <br />Thurstlay <br />Fntlay <br />Saturday <br />START ",STOP LESS <br />LUNCH REG.' <br />HOURS OVERTIME <br />HOURS <br /> yF.. <br /> <br /> <br />vv p a~/ . ~v <br />7 <br /> <br />~L.4.. 7 <br /> <br />rZLv <br />f <br />.J <br />i ~_. <br />~r 1T ,,. <br /> <br />-~ -% . <br /> <br />EMPLOYEE <br />'~~ I cerlily Nat.the lioure shown represent my btal-0ours waked during the <br />eek and thetlhey,were properly vedt etl by the client or by an authprized <br />rep esentelrve: Also, any work relatetl nlu e6 were repptled to $eledemp <br />al lhetme of injdry See eve eb lurthe inlormatioa ' <br />/l-;Z/_ <br />X ~~%/' c, P~l'a , <br />Signature of Employee ' <br />CLIENT <br />We realize that Ic transfer oneof Selectemp's employees to our <br />payroll requires a settlement. See reverse far further intormflticn. I <br />., hereby ceRity t t [he above hours a cortecl. <br />S gnaturepl Supervisor <br />~n~ TOTAL TOTAL' ,_(yj.~., /' J~ l /~-~Z -r(~t <br />~ r ~y„'} 7 V 1 <br />Hours to nearest quarter hour. ~.~,.~ Title - Date <br />CUSTOMER COPY <br />worked tlurirg the <br />rt by an euNorixed <br />mled to Seledemp <br />our <br />Hours to nearest quarter hcuc <br />