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A LK ILMP <br />EMPLO <br />EMI L0YM ENT <br />SE RVI I E S. <br />,i P.O. Box 71250 •, Eugene, OR 97401' <br />PI FACE PRINT <br />COMPANY NAME <br />I EMPLOYEE NAME <br />taG:r <br />SOCIAL SECURITY NUMBER <br />''COMPANY. NAME <br />oT <br />JOBSITE NAME AND/OR PO# <br />WE ENDING DATE <br />X1_0 10 <br />❑ ASSIGNMENT COMPLETED IP*RETURNINGNEXTWEEK <br />HAVE YOU HAD AN ON THE JOB INJURYTHIS WEEK? <br />YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />S <br />E MR 10 Y M E N T. 6 E A V I. C S <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT: <br />- EMPLOYEE NAME <br />EMPLO <br />rlE lrojn l / \ � I` en <br />AEG <br />HOURS <br />SOCIAL - SECURITY NUMBER <br />'3`1 <br />COMPANY NAME <br />q!13`C <br />t r <br />JOBSITE NAM AND/O PO# <br />WEEK ENDING DATE <br />G�c7/10 <br />❑ ASSIGNMENT COMPLETED L:1 RETURNING NEXT WEEK <br />HAVE YOU HAD AN ONTHE JOB INJURY THIS WEEK? '.. <br />❑`/ES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />0 NO <br />SIAHI I UIVP', <br />Tuesday y Of) 3.1 3z) <br />Wednesday j'.:) : 3, 3Z . <br />Thursday ? - � . fJl2f x 7 7 .5 . <br />Friday 7 .0 ti <br />Saturday <br />Hours to nearest quarter hour. <br />COPY <br />Sunday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />SE LE(T I M P Sunday <br />E N P L 0 Y M E N T'. S E R Y' I(' ES <br />P.O. Box 71250 • Eugene, OR 97401. Monday <br />PI FASF PRINT <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />EMPLO <br />NAME ' <br />AEG <br />HOURS <br />0.sntror) Allcn <br />Data <br />SOCIAL SECURITY NUMBER <br />q!13`C <br />t r <br />C NAME <br />7:00 <br />I C-pl C+1P_ <br />JOBSITE NAME AND/OR PO# <br />WEEKENDING DATE <br />3/ G'bt� <br />❑ ASSIGNMENT COMPLETED PkETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />P NO <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />AEG <br />HOURS <br />OVERTIME <br />HOURS° <br />Data <br />7:00 <br />3'00 <br />3o <br />75' <br />7:00 <br />3:010 <br />30 <br />"1 <br />TW <br />3,30 <br />1oa <br />3..� <br />3 <br />- <br />O.T. HOURS '- <br />EMPLOYEE <br />I Oedlly II the hours shown represent my total hours worked during to <br />weeks thetthey were p'apmly ver adient or by nauthonred <br />hearese t ivai'Also any. work relate were raportetl to Selectamp' <br />at that A (injury See reverse for r ormadon. <br />SSignaW a of Emplo <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />m roll requires a settlement. See eversedor further Information. I <br />ereby certi that the ab( /o}({e /'},lours correct. <br />X L V1 <br />Slgnatu <br />k <br />of SupeMSdr <br />S <br />z- <br />Title <br />- <br />Data <br />"EMPLOYEE. <br />I chi diQl She hours shown represent m'yltot I hours worked du ing the <br />week e tl Ihgt they were properly verif�g oy the d ant or by an our rizetl <br />rep e6entallve: Also any work relatetl u s ere reported to S'leotemp <br />at that eof injury. Sea reverse for luTle Irmelon.. <br />X. <br />i r <br />Signature f Employee <br />CLIENT <br />We re alize that '. to transfer one of Selectemp's employees to our <br />payroll requires a sentiment. See TSverse for further information. 1 <br />hereby car that the above hours are correct: <br />X <br />Si9natti of Supervisor <br />TOTA TOTAL 11 1 YI�YV�. �.AP L `Z G?. <br />Hours to nearest quarter hour. ,UTlle <br />CUSTOMER -0OPY, <br />START <br />STOP <br />LESS <br />LUNCH <br />"BEG,_ <br />HOURS <br />OVERTIME <br />'HOURS <br />7:00 <br />3'00 <br />3o <br />75' <br />7:00 <br />3:010 <br />30 <br />"1 <br />7,0o <br />3,30 <br />1oa <br />3;00 <br />6.7.5 <br />Hours to nearest quarter hour. <br />OT HOURS. <br />EMPLOYEE <br />I rl0 Ihal the hours shown represent my total hours. worked during the <br />week, that they ws p veri d thachera or by an aNFodzetl <br />repres fl,: "I any wro k relatetl ere ropened to Selectemp' <br />et the t e oo i See averse for W I hinnualar. <br />Signature of Employee <br />CUSTOMER COPY <br />