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StL C l tlhh _! <br />EMDlOYMENi SERYI(ES'~I <br />P,O. Box 71250' • Eugene. OR 97401 'F <br />PLEASE PRINT <br />j EMPLOYE NAME. <br />r^ <br />A• +~ <br />f <br />SOCIAL SECURITY NUMBER i; ~~ <br />`! <br />~, CcOMPANY NAME <br />r ~. r <br />~_ ~.:3 t :.~.-, ;:, <br />JOBSITE NAMEANDIOR POn <br />7 <br />1 r <br />WE K ENDING DATE <br /> <br />^ ASSIGNMENT COMPLETED RE7URNING NE%T WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^ VES IF VES.NOTIFV SELECTEMP IMMEDIATELY. <br />T'~ NO <br />SI:ECT P <br />EMPLOYMENT SERVI{ES <br />PO. Box 71250 Eugene, OR 97401 <br />PLEASE PRINT <br />010.H <br />Montlay .~ f ', ( i-lT <br />Tuesday ,~ ~, . ~ L~ ~ r <br />Wednesday <br />~- <br />~ ~ <br />~ =:~ <br /> '-'" <br />7hursaey .- <br />Friday '~ / •~~~ Y~ <br />Sawrday <br />TO?~ <br />Hours tonearest quarter hour ~~ <br />1 <br />CUSTOMER COPY ~ . <br />.START STOP LUNCH- HOL <br />{ <br />Sunday ~] <br />~" Mandey p.~. ~ ' ~ '( r <br /> EMPLOY ENAME <br /> <br />'SOCIAL SECURITY NUN <br />ER; <br />~ <br />!, ! i;: <br />C~MP NAME _ , <br />~ <br />1~ ~.;~~' I~.. ~^ ~rh ~ <br />$ E NA E AN~ !OR PO# <br />JOB <br />ry <br />k ~Gc~~ <br />~^/EE ENDIrNG/~.\p\ATE <br />^ASSIGNMENT COMPLETED `RETURNING NEXT WEEK <br />HAVE VOU HAD AN ONTHE JOB INJURY THIS WEEK? <br />^ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />^ NO <br />Tneadey. ! ~ ~ '7~1 ~,~, <br />Wednesday "~. '?V• ~ °"" <br />~'Thurstlay - ~ ~ <br />~ ~:' <br />C <br />Fritlay ~ !~ <br />~ ' <br />~y- <br />•zf ''7' <br />^ <br />'f`"'~ <br />Saturtlay <br />Hours to nearest quarter hour. <br />REG HOURS; '~ OT HOURS Fi <br />C,~. ~' <br />EMPLOYEE' <br />' ~ I:cemry That the hours shown repreaent my mtel hours worked during the <br />' week, entl ifiel they were,properly ve f tlby lh client or by en euNOrized <br />representative Also any o k fated W e a reportetl to SelevMemp <br />at the~lma 6~l ry ee ev v ~I lurf6er ormation. <br />Slgna(ure of Empl <br />CLIENT <br />Wa realize that to transer ono of Selectemp's.employees teour <br />Rayrpll requires a settlement See reverse'tp/further lnformallon.I <br />ereb/yj c~efr/t~~y Ihet the (a/bove hours era correct. . <br />~X `li-L'M'~l ~~ <br />$gnat 1e 016npeMBOr ,. <br />tL ~~4lLnl S~nJ" l -Z , -tv <br />Tnle ~ Date <br />HOURS REG: <br />EMPLOYEE <br />I certify Ihat the hoursshown represent mylelal hours Worked tldridg the <br />week; arrtl Ihafthey were prdperly verifietl by Ne client pr by en amhonzed <br />. represemat ve Also arty rk relatetl I re reporletl to 6eleitemp <br />at ih~ 1lnldry Sea reverse r,Il'u~;rlih'9_p~nf rmalion. - <br />is S9nmure of m e / <br />~ CLIENT, <br />Wa realize That to transfer one of.Selectemp's employees to our <br />payroll requves a settlement. See reversefor further Information. I <br />hereby cerlNy tat the above hours ere c rrect. <br />X ~- c.~~_ <br />Sgnalur oi8upervisbr <br />TorAL ',. ti11~'-WC SCD!?J. ~ Z "S~'.ZO! p <br />. Title Date : <br />' ~ CUSTOMER-0OPV ~ :~ . <br />__t --_ SELECTEMP <br />EMDLOYMENT SE RVI(ES <br />P.O. Baz 71250 • Eugene, OR 97401 <br /> START STOP <br />Sunday <br />tla <br />. <br />' Mo <br />y <br />n <br />Tuestlay ~ .~ <br />SOCIAL SECURITY NUM6FyA,.~~r <br />~~ (r) <br />-COMPANY NAME <br />l i. `( -' l ~'. <br />J0851TE NAME AND/ H r~» <br />It <br />~I~ DAt~V. , <br />ASSIGNMENT COMPLETED C~ RETURNING NE%T WEEK <br />.._... ,... ,.~ nr.r ruc IOB INJURY THIS W EEK? <br />Wednesday -~ <br /> ^T <br />ThurstlaY m .a <br />Friday ~. '~ -,5 <br />$alurtlay <br />IoT, <br />~~~ 'f'C~ <br />_7 ~, ~ ~- <br />UIyJ I t J <br />f ..~ 1 <br />Hours to nearest quailer hour. <br />EMPLOYEE <br />I cetllfy Nat the noursshawn repre nt my total hours worked tluring iM <br />week, entl that Ney vrereproperly ve fetl by the client or hY an authorizes <br />wor relat d'nj des wo/R.r ortetlld SNebteml <br />at ~atnteOVe. Also, arty. rs~forfurtft~in~l~f <br />' ry: See ,//'' <br />~r <br />X Lure of plaYee ~' _ <br />CLIENT <br />payrollarlegmms a~seltlemeni Seei re/verse oPiurihePlin ormatlon <br />hereby certify hat the ebwe hokrs era °grrect. <br />X: ~. I~~. l/~(/c...jJ1r~~. <br />Signatbr of Superv sor '. <br />I / _ ,1 0 _ 7~ .. /r~ <br />