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Sk tC ! tr'I <br />EMD. LDYMEXi SERYIGfS <br />P.O. Box 71250 Eugene, OR 97401 ; <br />Rt cacF.licinlT <br />) EMPLOYEE NA~E <br />SOCIAL SECURITY NUMBER <br />,. <br />.~ ^> <br />f _ COMPANY NAME <br />r ~ <br />r•., v <br />L,. t ' F' i , I t'~ w ~~. <br />JQeSITE NAMEAND/OR PON~ <br />,WEEKENDING DATE <br />^ASSIGNMENT COMPLETED "~RETURNINGNE%T WEEK' <br />HAVE VOU HAO AN ON THE JOB INJURY THIS W EEK?( <br />^ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />~~NG <br />EMDLDYMERi SERVICES <br />P.O. Box 77250 • .Eugene, OR 974Di <br />OI FCCF PRINT <br />EMPLOY EVtVAME <br />LGG~'t ~U(. <br />'SOC19L.~ C`U'7RITY.NUMBER <br />rt, / <br />.y' <br />1 COMPANY AM .- `T <br />J0B31yEy`IAMEAND/OR PO#'J~ <br />19q <br />t ~:: <br />WE KENDIIJ~p ATE <br />_.. I ~_.. (Y. <br />^ASSIGNMENT COMPLETED QRETURNING NE%T WEEK <br />HAVE VOU HAD AN ON THE JOB INJURY THIS WEEK? <br />^ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />C3'NO <br />Watlnesdey <br />'„Frltlay <br />$zturtlay <br />Monday <br />Tuesday <br />Wednestley <br />Thurstlay <br />Frltlay <br />Satureay <br />cx~ ~ ~, fit. ' 1 , <br />Hours taneHYest quarter hour <br />CIICTtlMFR CARV <br />i EMPLOYEE <br />t cedliy Nsi IHs ho shown repress t y total hours worketl tlur nj Ihe.. <br />weak antl that they ware properly veriletl Cy the dent orMan aulhprrzed <br />~,representat ve Alsq eny wo k relateq ntures are reportetl to Seledemp <br />et Iha hme of inryry ee reverse for lu the nlorme on. - ' <br />t <br />regneWre of mployee '. <br />CLIENT" <br />We reeliie Thal Yo iransierbne of Selectemp's employees to our <br />/ payroll regmresa aritlement. See reverse far lurther'iniormation. I <br />hereby cerhi that the above h~o~urj/~J~are wrrebt. ' <br />-&gnetu of SUpervissr..! ' <br />Ttle Date . <br />n .+,; <br />START STOP 'LESS '~ <br />LUNCH ~''REG <br />HOURS'.. OVERTIME <br />HOURS'. <br /> <br />•~J <br />c • ~L;,~ n~ ~sS' <br /> <br />_~ i ~'~.. <br />., ~~..~ <br />) off. -7 <br />f e s <br />-~;; <br /> <br />v~ ~,~- ~`? -~,S <br /> <br />LGCI\ 1 <br />We7ealize.ihet to Vflnster one of Selecleldp'semployees io our <br />' payroll requires a settlement. See reverse for furiheYiniormalicn. I <br />hereby certify that the above hours ar correct. <br />5 gnat ~ of Supemspr <br />TQTAL TOTAL Cp <br />Hours to nearest quarter hour. S<]V~j }`~~'4~~ JV{! 1~ Z - (L ~ ~ V <br />a ' 7ne Dale ' <br />CUSTOMER COPY <br />S .CT:~P . Sunday <br />"' EMDLOYM.ENE SEftYIC.ES Monday <br />P.O. Box 71250 • Eugene, OR 974D1 <br />EMPL~VEE NgME <br />~G ~C ;f'1 --~;j'v1 <br />SOCIAL SECURITY NUMBER- ' <br />C.u 1 ~' <br />"~t COMPANY Nq ~,.~ ,t <br />1 Fl..-? ~-'J <br />J,Q S_ ITE NAME ANDlOR PO# <br />i /FEEK EJV,DING DATE ., <br />/Jt~ !f <br />j <br />^ASSIGNMENT COMPLETED (~AETURNING NE%T WEEK <br />HAVE VOU HAD AN ON THE J08 INJURY THIS W EEK? <br />^ VES ` IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />© NO ' <br />mwHl aI~H, ~.LUNCHS ~~'.HOUflS ..HOUR: <br />l < <br />$untlay .. <br />.} ~ ~. <br />Monday , :C> Jt, .~}_,. "~. <br />' Tuesaev }:1~6 J.N.. •`^ ~f.~,+ <br />Tuestlay <br />'Wednestlay <br />Thurstlay <br />Friday <br />$elurtlay <br />START STOP LESS <br />LUNCH REG <br />HOURS OVERTIME <br />HOURS <br /> <br /> <br /> <br />~; o N 33~` ;~ ~ ' <br />~,~ :~7 <br />~C~~ 3:~~ ,S r..~ <br /> <br />FOR OFPICE USE ONLY <br />'REG. HOURS. - OT HOURS <br />EMPLOYEE <br />Y ceriy Nat the hours shpwq represenfmy total hours woAetl tlurinq,lhe <br />reverse <br />-'~ CLIENT <br />We realize Ihafb Irahsler one of Seleclemp's amployses9o our <br />Rayrpk requires a settlement. See reverse far luriher information. 1 <br />ereby cerlif That 1He above hours ar~carrect. <br />Hours to neareri quarter hour. j ~J <br />n. ~•.+•.um'i•nev <br />~~~~'. <br />Data <br />