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SEL.E(TEMP. <br />EMDL0Y.MENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIKIT. <br />START STOP LESS REG OVERTIM FOR OFFICE USE ONLY <br />LUNCH, HOURS HOURS E& HOURS O.T. HOURS ' <br />Sunday <br />Monday <br />Tuesday <br />EMPLOYEE <br />I certify that the hours shown represent my total hours worked during the _ <br />week, and that they were verified by the client or by an authorized <br />^ 3 <br />r'1 <br />V <br />((1 <br />properly <br />representative. Also, any work related injuries were reported to Selectemp <br />at the timeof injury. See reverse for furt r information. <br />Wednesday <br />Z: 30 <br />3 0 <br />w <br />Thursday <br />7 <br />( <br />Signature of Employee <br />U <br />CLIENT <br />;Friday <br />Z1 <br />�v <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requires settlement. See reverse for further information. I <br />hereby t �t the <br />' <br />p <br />certify ab a correct. . . <br />Saturday <br />X. <br />. <br />,. <br />TOTAL TOTAL <br />Lure of SupervIs ^^ - - <br />Hours to nearest quarter <br />hour. <br />(/ <br />.Title Date <br />CUSTOMER COPY <br />EMPL � YEE NAME <br />� <br />lc� � cc,�:`e <br />S CIAL SECURITY NUIMBtR <br />COMPANY NAME <br />JOBSITE NAME M D/OR PO# <br />WEEK ENDING DATE <br />0 ASSIGNMENT COMPLETED. ? RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO .. <br />