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SLf TEMP <br />EMDLOYM E'NT S.E RYI(ES <br />P.O. Box 21250 ~ Eugene, OR 97401 , <br />PI FARF PRINT <br />EMMPLOYEE NAME <br />_.t~ ICS' aoY~rt S <br />' SOCIAL SECURITY NUMBER <br />P332 <br />COMPANY NAME }, <br />JOBSITENAME AND/OR P <br />WEEK ENDING DgTE <br />a~ f~6 Jro <br />^ASSIGNMENT COMPLETED ~FETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />Li V S IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />~O <br /> START STOP ',,,LESS ,REG' OVERTIME ', '1 V1( VCMI.E VJC V1VLI <br /> , LUNCH HOURS NOURS .REG: HOURS' ~ ~ -OT HOURS'' <br />Suntlay <br /> . ~ <br />' MontlaY ~'~ 3~ '~ ~ <br />... T ~ '. <br />~ <br /> <br />Tuesday <br />~-fl0 p <br />3 -QQ , .. <br />~ 3~ <br />~•,~ ~ <br />:EMPLOYEE <br />~ I certgy the[ the hou s shown represent mytotal hours worked during the <br /> _ weak, antl that they wBra.properly verified by the client or by an aulhwixed <br />reseMatlVe Also an <br />work 2latdd m <br />otletl to Seldblemp <br />re <br />unes wore re <br /> <br />~Wednesdey <br />~.60 <br />~'~Q yy <br />:Jb ~ y <br />p <br />t <br />p <br />aUhe lime of lnlury. See raaerse urAer nformat on <br />' " X ~/ <br /> <br />Thursday ,~~ <br />~ •^f3 3=Q6 <br />~.~ <br />7-i'~. Sigheture of Erh yee, ., <br /> - CLIENT ~ ' <br />' <br /> <br />Friday <br />~pO ~ OD <br />:~ 0 <br />~5 'We realize that td Vahafar one of Selactemp's employees to our <br />payroll regmms a settlement. See reverse for further InbrmaHOn. I <br />h <br />t th <br />b <br />h <br />t <br />- <br />". h <br />d <br /> a <br />e a <br />ov <br />o <br />are <br />. <br />ereby cer <br />t <br />rs <br />Y <br />/ <br />)//rec <br />e/ <br />c/ <br /> • ( <br />~_ <br />/ <br />~ <br />~ <br />~ <br />/ <br />y <br />- <br />~ <br />_ <br /> <br />-°. <br />..TOTAL TOTAL <br />~ SglnelzW~rof SUpe(rvji~soAr / - <br />~h l~'{~~ ~/~1'.Il ~...C~.'i ~OI~ <br />7 <br /> Hours to nearest quar ter hour ~ ~ <br />- <br />The Oats <br /> CUSTOMER.COPY <br /> <br />~~F`,~-.\' ~i ~Y Sunday. <br />EMDL.DYM.E'NT SERVICES ' <br />P.O. Box 71250`•' Eugene, OR 97401 Monday <br />PLEASEPRINT_ ___ <br />EMPLOYEE NAME <br />T le.r ~I'Jor-ri S <br />'SOCIAL SECURITY NUMBER <br />C:*':?~ <br />COMPANY NAME ' <br />~~ir7 ~ nF ,, ,.~lA R2 /LC' <br />JORSITE NAME AND/OR PO# <br />.WEEK ENDING DATE <br />- ~ ~' f ';~ f t ~, <br />^ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />~YhVES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />Y] NO <br />'Tuestlay <br />WeEnesday <br />Thurstlay <br />Fnday <br />$aWrday <br />START <br />.. -STOP <br />. .._...., ~ " LE5S <br />LUNCH~.: - 'REG <br />..HOURS- OVERTIME <br />HOURS <br /> <br /> <br /> <br /> <br /> •~ <br /> <br />HOURS O:T. HOURS <br />EMPLOYEE <br />I'cArtity 1hatThe hours shpwm represent my tplal hours worketl tluring the <br />riaek, antl that they,were properly ver iietl bythe client orby an aumorrzatl <br />~' represenrativei Alagany.work relatetl injuries were Feportpd to Selectemp <br />`atthe time of injury Seere ers for further nlomanon~~ <br />' S gneture of Employee ' <br />CLIENT. <br />We. realize [haT tb iransler one af'Seled[emp'semplbyees to our <br />;. payroll requres a settlement See reverse for further information. I <br />hereby/~certi thatlhe ab/o/ve ours ewReq. <br />SigneWr~ of Supervisor <br />' TOTAL TOTAL- ~.,y,, <br />Hours to nearest quarter hour. '~t2NV~~ SuDJ` Z'IZ.' V <br />38 Ttle <br />' CUSTOMER COPY <br />l E ! T E P START STOP .LESS REG OVERTIME FOR OFFICE USE ONLY <br />LUNCH HOURS HOURS '~ <br />' REG.HOURS O.T. HOURS <br />.Suntlay <br />E ~.M.D LO-MEW3 SE RV:I<E'S Mpnday. <br />-P.O. Box 71250 •'.Eugene, OR 9740T. <br />-, EMPLOYEE <br />EMPLOYEE NAME <br />SOCIAL SECURITYNUMBER <br />~)': Z. <br />COMP~NV NAME <br />JORSITE_NAME ANDlOR PO# <br />' WEEK ENDING DATE <br />'^ASSIGNMENT COMPLETED K]RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />Q VES IF VES,NOTIRV SELECTEMPIMMEDIATELY. <br />Tuestlay a77. <br />r7 % `~7 ) ref ..., - ~I cerfiry that the hours shown represent my total hours worketrtluring Iha- <br />th <br />i <br />ed <br /> . <br />~' or <br />z <br />week, and that ttiry wefe gopatly verinetl by lire diem o1 by an au <br />- ep s tatrve. Als ny work relatetl Inlu les ware reported m S lectemp <br />~ <br /> ' el Me time injury Seerey rse for lutlhe formation <br />J <br />WetlnestlaY 1 <br />/ =9 y1 ~:?~ / <br />~ } ~'j <br />l3 _ ff <br />' <br />'• <br />~" C <br />~' <br />'~L/" <br />-~ <br /> . . _. <br />X <br />~•:.. <br />~ <br />Z` <br />JLt-era-! <br />Y <br /> <br />Thursday <br />T ;'7? <br />5:'7) <br />, t> <br />~ ;'y, ~ Slgnaiureot Empl yee - ~ ~. <br /> CLIENT <br /> <br />'f,' S <br /> <br />~^ y~ <br />C <br />l <br />y <br />7 <br />2 ~ Wa realrze that to transfer. one of Seleclemp's employees to out <br />payroll requires a settlement. See reverse br further mfonnation. I <br />Fntley " • c~r fy.ihat the above hour are correct. <br />hereb <br />y <br /> / <br />~ <br />3( <br />/ r_ <br />rJdinrday <br />.. ~ <br />' Sgnat~re of SUpeM%r <br />. :. XTOTAL <br />9 <br />a5 TOTAL - ~1n -, CJD/- Z "E ~i -I~ <br />\KA't'1 <br />Hours to nearest quaver hour .•' <br />- Date <br />Title <br /> <br />