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~tLtCltl~h <br />FNPLOYNENT SERYICES <br />P.O. Box 71250 • Eugene, OR97401 <br />PLEASE PRINT <br />EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER <br />`I <br />COMPANY NAME <br />WEEK ENDING DATE <br />i'. <br />^ ASSIGNMENT COMPIETED ~~RETURNING NE%T WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />~'NO - <br />SELECTS P <br />EMPLOYMENT SERVICES '. ,. <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI F6CF PAINT <br />f, EMPLOY NA <br />~ cl stn ~ a~s" <br />rJ SOCIAL ECUR TY NUMBER <br />~ ~y-- <br />(~^. <br />COMPANY NAVMEC <br />LrSI. @irl ~. /a~F-r <br />y BSITE NAME AND/OR POn. <br />~I~~~ ~-vail <br />i WE/EKENDING DATE <br />i G-~.~i 1 ~ L~ <br />^ ASSIGNMENT COMPLETED RETURNING NE%T WEEK <br />HAVE YOU HAD'AN ON THE JOB INJURY THIS WEEK? <br />^ VES IF YES, NOTIFY SELECTEMP IMMEDIATELY <br />^ NO <br />SELECTS P <br />EMD LOYM&NT SERYI-(ES <br />P.O. Box 7125D • Eugene, OR 97401 <br />,, <br />'~'~ EMPLOYEE NAME r <br />SOCIAL SECURI, V NUMBER <br />r~ - yr~- <br />COMPANY NAME' <br />~LI'dLJv~ .,~ ~~'~ rJ~$ <br />, JO ITS NAME ANDlOR POri <br />WEE{~ENDING DATE <br />(= rZ <br />^ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^ `!ES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />Suntlay <br />Montley <br />Tuesday <br />Wetlnastlay <br />Thursday <br />Fdaey <br />Seturtley <br />Sunday <br />Monday <br />Tuesday <br />wednesday <br />Theretlay <br />;Fntlay <br />Saturday <br />$untlay <br />Montlay <br />Tueetlay <br />Wednesday <br />Thursday <br />Friday <br />Saturtlay <br />awm awr LUNCH HOURS HOURS- <br /> <br />._ ~t-. ~ .., ~ ,. <br /> <br /> rq <br /> <br /> _ , <br /> <br />' <br />Hours ro nearest quarter nour. _; TOTAL <br />{ ,Q ,! TOTAL <br />START'; $TOP~ LE$S <br />LUNCH REG' <br />HOURS OVERTIME <br />HOURS._- <br /> <br /> <br />f ~ JJ '~~. <br /> I <br />7 ~ ., 3,~ 7=5 <br /> yy <br /> ,, <br />. gEG:HOURS - O.T. HOURS <br />EMPLOYEE. <br />I certlly mat me noun ehawn represent mY Iplel M1oem workatl eurinp the <br />weak, erM Ihet they were properly verilietl by the client or by en eumadxed <br />rapreeentative. Alsq airy work related lotuses were reppnetl to Selectemp <br />al the tlme of Inlury. See reverse for lurlher Inbrmellon. <br />O.T HOURS <br />•y <br />EMPLOYEE <br />IseNly Nat the hours anown represent my total hours warketltlueng the <br />week antl that Ivey wars properly vans ee by the diem or by an zumorized . <br />representative: AISO, any work related Injuries were feportetl to Saleclemp <br />euhe lime of Inlury. See rertrse tortunhennbrmalion.: , <br />X Nz~:>Gr~, ~~1`' <br />'' SignaWrerotEmployee ' <br />'CLIENT <br />~. We'realizelhat to transfer one by Selectemp's amplcyees to our <br />payroll requires a seNemenl. Sea inverse far ludher intormahon. I <br />hereby rartil hat the abo ours re correct. <br />x Cl ~ i . ~~:' <br />S gnalurp of Sbperv sot. " ' <br />`IL <br />Hours to nearest quarter hour ry}~ <br />Y <br />C <br />START STOP LESS <br />LUNCH REG <br />HOURS OVERTIME <br />HOURS ~. <br /> <br /> ~,', <br />:~ ~5 , <br />-7 ~. <br /> C <br />~f Ji ,~,) <br /> C <br /> Fi <br /> <br />FOR OFFICE USE ONLY <br />REG HOURS~~ .~ OT HOURS . <br />EMPLOYEE <br />I cetlily final the hours shown repress I my total hours wprketl eating the <br />week, antl that they' eproperly wried by lne dienl orby an aumorizetl <br />representative. Also anywprk related nI es were reported to Se,eclemp <br />et the lime of lrUUky Se averse foRr lurlher irmauon: <br />X i P`:(U.L~ J~,. ~ij/k <br />S!grature o=EjnPloyee. ~ p ., <br />°. CLIENT <br />' We realize Thai to transfer one of Selecternp's employees to our <br />' payroll requiresa settlement. See reverserFOr turiher Inbrmation. b <br />hereby car fy that the above hours are Detract. <br />`Xn_ ~~~ <br />Slgnal~re of Supervisor ~ r <br />1qT~ TOTAL ~'~ 1n(.}~JiJ l~V i ~. j Pa~ <br />1~ ~"~+~. <br />HOUra 10 nedr061 gllaflef nOpL TIXB ~ DBIe <br />rt Icrnn~FP rnov <br />