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! ~ ~ ~LtC l t~IU <br />EM.D LOYMENT SE R'Y I(ES <br />P.O. Box 71250 • Eugene, OR 97401'- <br />PI FASF"PRINT <br />)wq( LI EMPLOYE..{€_NAM <br /> SOCIAL SECURITY NUMBER. D <br />;•r~} (f <br />~.. /COMPA•NY NAME <br />L• \\ <br /> ITE.NAME~ ORPOk- <br />J085 <br />. <br /> ~rA <br /> _..~EEK ~NDING~DATE <br />f <br /> G. <br />l t(~ ' <br />° <br /> ! J <br />[[ <br />^ASSIGNMENT COMPLETED ~lt1ETURNING NEXT WEEK <br />VV <br />HAVE VOU HAD AN ON THE JO <br />B INJURY THIS W EEK? <br />^VES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />L'` NO <br />SELECTS P <br />EMDLOYME NT SERVI(ES~ <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />EMPLOYEE NAME <br />+a'~.`~ {1 <br />1~~t.V ! ~. ~~ <br />SOCIAL SECURITY NUMBER ' <br />l <br />//1 ~. ~ <br />COMPANY NAME <br />y ~ 2. <br />JOBSITE NAME AND/OR PON <br />-T; .:~ <br />WEEK ENDING DATE <br />{C1~ASSIGNMENT COMPLETED ^RETURNING NEXT WEEK <br />HAVE VOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^VES IF YEB,NOTIFV SELECTEMPIMMEDIATELY. <br />11 NO <br /> <br />- START STOP '.LUNCM. HOURS HOURS - <br />REG <br />HOURS ` <br />T: HOURS ' ' <br />O <br />Suntlay . <br />. . <br /> <br />- - <br />^} <br />MOntley ,~' ~ ~ q <br />f <br /> <br />TuBStlay <br /> <br />' ~Lr <br />7 <br /> <br />~) <br />"'~ f <br />/ ~ <br />~ r, <br />) <br />~ EMPLOYEE <br />I wrtiry Ihat Ilie ho rs shown'represe I my Imel hours worketl dunnB the <br />week entl that they were prppeey verf etlWme dent orWen auOOrizetl <br />utes arepOrletl to Salectemp <br />reaenta[ve <br />Als an <br />work relatetl <br />a <br /> <br />WetlnestleY ''^^~~''''jj <br />.,L <br />'"'l ~, <br />rs~ <br />< }~ p <br />. <br />y <br />l <br />at fig Np Ot njury Sa eve5e br lu Ihs l0 ali0n. ' ' <br />// ~. ~j~ `~-f}J`~, <br /> <br />Tnurstlav <br />_-.~.. <br />,.~ --°- <br />,``~+ : _ <br />~.1~ ~~ Signature of Elq oyee '~-- <br />.. ' CLIENT. <br /> <br />Fntlay -y~ <br />~ " 7 <br />~ <br />f l <br />~- ] <br />III We realize that to transfer one 01 Selectemp's employees to our <br />. payrolY requlrese settlement: See reverse for further inlorrnatioa 1 <br />~re correct' <br />hharsb <br />cerh that the above <br />hours <br />, <br />( <br /> /~1 ~ <br />~ <br />L <br />l <br /> SgndlUl 01 $UpeM50r <br /> <br />' <br />TOTA,4 <br />' <br />~ <br />( <br />T07AL ' l <br />{fit tp #'~ SJ 'Q ~ ~ - I Z' ~Ly. <br />"i <br />Hours to nearest quarter hour ~ <br />O r <br />Title - Date <br /> <br />j START STOP <br />Suntlay <br />Monday ~" Jj <br />~.7 ~ <br />Tuestlay, -r~ <br />I <br />Wetlnesdey it ~ ',~ <br />~Ttiurstlay - ~ . <br />.. Fntlay ' ,f . y <br />SatuNey <br />FOR-0FFICEUS <br />REG. HOURS - O.T. <br />,_ ...-; <br />~,< <br />r <br />-7 ~ ~ EMPLOYEE, <br />,t Icenily that the hours sM1awrt represent my toteth0urs worked during the <br />week entl met may were properly ver M1etl by the clien[or by en aNhOnzetl <br />. epresenlaHve: Also; arrywOrk related I Fies were reportetl ro Selectemp <br />_ at me llme of injury See reverse kr N,,tl(.hp_er inl0imatbn. ' <br />Si a[ure of employee <br />.~ <br />Hours to~nearest quarter hour. <br />CLIENT - '- <br />We realize that to transfer one of Selectemp's'emplcyees'to our <br />Rayrpll regl+l s a settlement. Sea reverse !br Further Inlormatwn. I <br />erehy ce I That the above hours are correct. <br />~X ,~ `G~.. (-~--= <br />Sjjign~~ature oflS~ulperviso~~r~~. I t{- - <br />TOTAL ~ ~. L..YA'D•//.J~F`~~.:. ~j~~'Iq f'O .. <br />Tllle : Date <br />' CUSTOMER COPY ~ ' <br />