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ELE(TEMP <br />EMPL'OY'MENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />'PI FACF PRINT <br />EMPLOYEE NAME <br />C Gl " 1 f V <br />CIAL SECURITY NUMB EA. <br />C NAME <br />E <br />JOBSITE NAME AND /OR 5 O# <br />WEEKENDING DATE_ . <br />.� ' <br />❑ ASSIGNMENT COMPLETED O'RETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YES . IF YES, NOTIFY SELECTEMP IMMEDIATELY. ' <br />NO <br />Sunday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />i - <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS' <br />LP <br />3o <br />Ce <br />Z 3 0 <br />3 <br />LP <br />3,.) <br />.30 <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 information. <br />Signature of Employee <br />CLIENT <br />We realize that to transfer one of- Selectemp's employees to our <br />payroll requires a settlement. See reverse for further information. I <br />hereby cer "fy that the above hours are correct. <br />x -�--_. <br />Si ture of Supery or h J <br />TOTAL TOTA / . f C-�= �V —/� <br />Hours.to nearest quarter hour. 3 O. D - Title' Date <br /><` y <br />CUSTOMER COPY , <br />