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SELE(T E M P. <br />E MP L0YMENT SE RYI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />541.746.6200 Fax 541.746.7380 <br />PLEASE PRINT <br />ra�1 <br />EMPLOYEE NAME <br />PO <br />LESS <br />LUNCH <br />Ye <br />3� 53 <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />cal �d (ne <br />T oo <br />WEEK ENDING DATE <br />5 <br />- i, S <br />UASSIGNMENT COMPLETED ❑ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURYTHIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />VNO <br />Sunday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />8TOP <br />LESS <br />LUNCH <br />AEG <br />HOURS <br />OVERTIME <br />HOURS <br />T oo <br />5 <br />- i, S <br />71c,c, <br />3.00 <br />.fa <br />3 <br />S <br />TOTAL TOTAL <br />Hours to nearest quarter hour. v) <br />FOR UNNl(:h USE UINLY - <br />REG. HOURS O.T. HOURS <br />EMPLOYEE <br />I certify That me hours shown represent my total hours worked during to <br />week, and that they were properly verified by the client or by an autorized <br />representative. Also, any work related injuries were reported to Selectemp <br />at the time of injury See reverse for further Information. <br />X I <br />Signature of Employee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />ec ymll requires a settlement. See reverse for further information. I <br />.by ca Ify that the shove hours re correct. <br />$ net set $U aN,.or <br />P•60 ")'7I/ � Z It <br />Title I Date <br />WHITE: CUSTOMER COPY YELLOW: EMPLOYEE COPY HARD WHITE: SELECTEMP COPY <br />