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ELE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI FACE PRINT <br />EMPLOYEE NAME <br />CIAL SECURITY NUMBER <br />COMPANY NAME . <br />JOBSITE NAME AND /O PO# <br />WEEK ENDING DATE <br />❑ ASSIGNMENT.COMPLETED OETURNING NEXT. WEEK <br />HAVE YOU HADAN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />El NO <br />Q.nday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />.STOP <br />LESS' <br />LUNCH <br />- REG <br />HOURS <br />OVERTIME. <br />HOURS <br />�J <br />S <br />8 <br />6 10.. Z-• 3o, 5 <br />'. <br />FOR OFFICE USE ONLY <br />HOURS O.T. HOURS <br />EMPLOYEE <br />,I certify: that the hours shown represent my total hours worked during the <br />week, and that they were properly verified by the client or by an authorized <br />representative. Also, any work related injuries were reported to Selectemp. <br />at the time of injury. See reverse for further infor . on. <br />X <br />Signature of Employee <br />. CLIENT <br />Wwrealize,that to transfer one of Selectemp's employees to our <br />payroll. requires a settlement. See reverse for further information. I <br />hereby cer Ify that the above hours are correct. <br />ature of supervijor <br />TOTAL TOTAL <br />3 � : <br />Hours to nearest quarter hour. <br />.Title - Date. <br />CUSTOMER COPY <br />