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s <br />SOCIAL SECVR1TY NUMBER > <br />MKILMP <br />'. JOBSITE NAME AND /OR.PON' ' <br />EMPLOYMENT <br />SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />GI CACCCGQJT - <br />'I <br />START STOP 'LUNCH. HOURS HOURS <br />REG HOUHS" D.T. HOURS <br />' Sunday " <br />c <br />Monday <br />EMPLOYEEI' <br />_ t EMPLOYEE NAME <br />1� SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />JOBSITE NAME AND /OR POM <br />I WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED VJ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />Q YES IF YES, NOTIFY SELECTEMP IMMEDIATELY., <br />NO <br />Tuesday <br />Wednesday <br />SOCIAL SECVR1TY NUMBER > <br />t OMP NY NAME - <br />` �uct�4"f,� ' <br />'. JOBSITE NAME AND /OR.PON' ' <br />`T _ <br />_ <br />NDING^ <br />e e that me hours shown represent my total hours during The <br />ree k, a nd that they y Necl eore by an nza6 <br />to Setectemp <br />representative. Alegi shy work ho relateitudin1 red were reported rd Sel.c <br />al the time of inluiy See reverse for further information. ^ , <br />f <br />'I <br />Signalure of Employee <br />Thursday <br />.: ", <br />Wednesday <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />Friday <br />_ <br />I _ <br />proll req 1 a settlement. See reverse focfurther information. I <br />he <br />rvty althe above hour arec Cott. <br />,r <br />Saturday <br />Signature of Employee - <br />Thursday <br />�' S <br />Signaturb of Supel/ rvv'isorfy' <br />' <br />TOTAL TOTAL <br />941 '11 V ( l. <br />We realize that to transfer one of Selecfemp's employees to our <br />Hours to nearest quarter hour " "it`,',L <br />- The 1 Date <br />CUSTOMER Copy <br />Saturday <br />SELEGEMP S unday START STOP <br />E M P L O Y M E N T, S E R VICE S <br />P.O. Box 71250 • Eugene, OR 97401 - Monday <br />PLEASE. PRINT. _ <br />EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER. <br />COMPANY NAME <br />JOBSITE NAME AND /OR PO& <br />- WEEK ENDING DATE <br />ASSIGNMENT COMPLETED Q RETURNING NEXTWEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES; NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />REG: HOURS' 'I O.T. HOURS , - <br />I . <br />EMPLOYEE <br />Tuesday <br />SOCIAL SECVR1TY NUMBER > <br />t OMP NY NAME - <br />` �uct�4"f,� ' <br />'. JOBSITE NAME AND /OR.PON' ' <br />1'r <br />NDING^ <br />I randy that the hours shown represent my total hours worked during the <br />week; and brat " were property verged by the oient or by an authorized <br />_ .Presentative. any work related injuries were reported to Selectemp <br />THE JOB INJURY THIS WEEK? <br />ELECTEMP IMMEDIATELY. <br />- <br />Wednesday <br />at the time of injury. See reverse for thither infrounaton. - <br />+ <br />Signature of Employee - <br />Thursday <br />�' S <br />- <br />CLIENT <br />We realize that to transfer one of Selecfemp's employees to our <br />Frida y <br />!'T rs <br />payroll requires a settlement. See reverse for further information. 1 <br />' h%Io cert ' that the gib ours re correct. <br />Saturday <br />X <br />Signatu a of Supervisor ' <br />' <br />Hours to nearest quarter hour. <br />TOTAL <br />30 r 5 <br />TOTAL <br />_ <br />Title Date <br />CUSTOMER COPY <br />START STOP Lobs <br />LUNCH l <br />SELECTS P Sunday <br />EMPL0YMENT SE RV.I CES �¢t <br />P.O. Box 71250 • Eugene, OR 97401 Monday, <br />PLEASE PRINT <br />. 7 MPLOYEE NAME <br />SOCIAL SECVR1TY NUMBER > <br />t OMP NY NAME - <br />` �uct�4"f,� ' <br />'. JOBSITE NAME AND /OR.PON' ' <br />NDING^ <br />D RETURNING NEXT WEEK <br />EASSI GNMENT <br />THE JOB INJURY THIS WEEK? <br />ELECTEMP IMMEDIATELY. <br />Tuesday <br />l .,Thurstlay <br />Fudav <br />Saturday <br />Hoots to nearest quarter hour. 'J,, <br />CI IRTOMFR COPY <br />E <br />-+ mreN that the hours show <br />' we reabxa'1115 to <br />i'p ayroll requires :a <br />.hereby cert 'tfi <br />X f � <br />Sgnet re of Superv, <br />TOTAL <br />ntYNM1`� <br />Title <br />r. <br />mps employ sto <br />or tuner Infor#natG <br />ct . <br />1 "'2 5 -- �' V <br />Date <br />Hoots to nearest quarter hour. 'J,, <br />CI IRTOMFR COPY <br />E <br />-+ mreN that the hours show <br />' we reabxa'1115 to <br />i'p ayroll requires :a <br />.hereby cert 'tfi <br />X f � <br />Sgnet re of Superv, <br />TOTAL <br />ntYNM1`� <br />Title <br />r. <br />mps employ sto <br />or tuner Infor#natG <br />ct . <br />1 "'2 5 -- �' V <br />Date <br />