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SLCT <br />E MDLOYMENi SEftVI'(ES <br />P.O. Box 71250 • Eugene, OR 97407 <br />PLEASE PRINT <br />EMPLOYEE NAtdE <br />T,~ fl,:~~ .Cl o rr I S <br />SOCIAL SECURITY NUMBER <br />5?` ? <br />COMPANY NAME '' 1t ~^ <br />J06S'ITE NAME AND/OR POi! <br />WEEKENDING DATE <br />ASSIGNMENT COMPLETED ^RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS W EEK?. <br />p VES IF YES, NOTIFY SELECTEMP IMMEDIATELY <br />~~ ND <br />Suntlay <br />Montlay <br />Tuesday <br />Wetlnestley <br />Thursday <br />friday <br />$atdNay <br />START STOP , LESS <br />LUNCH PEG". <br />HOURS OVERTIME <br />HOURS <br /> <br />~/ <br />r:~7 <br />~iS rr <br />.,},, <br />'ll:ys 3 ~~~ ~~ a z!S <br />r' , n o .. <br /> <br /> <br /> <br />FOR OFFICE USEONLY ' <br />REG. HOURS O.T. HOURS - <br />EMPLOYEE <br />I Cenlty Ihdi the hours sM1nwn represem mY total hours woiMea'aunng me <br />week, flntl lM1edM1ey eepraperly vent tlby me lent arW en autM1anzetl <br />represantaLVe.'Also any work relaletl nl es ere reporletl to Seledemp <br />al Iha time of Injury See reverse br fu~rth~er~-Nyo~ ma4an. <br />Signature of Empl <br />J' <br />- CLIENT <br />We realrze that to fransfer one of Selectemp's employees to our <br />payroll requires a settlement. Sea reversebr further Inbrmalion. I <br />hereby ce y'ihat the above hours are correct. ' <br />SignaMre oRSUpervisor <br />~eu~gw, F IrA2 ~ 3~1 i q ~ lD <br />Tile Dale <br />' TOTAII]'. TOTAL <br />Hours to nearest quarter hour ~I~+" <br />CUSTOMERCOPY '~ <br />