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E L E( T E M P <br />EMPLOYMENT SERV.I(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />/ J A EMPLOYEE NA ` <br />SOCIAL SECURITY NUMBER <br />Cc C&PANY NAME <br />U ~� <br />A ND/Op PO# <br />G a JQB�E� <br />N <br />WEE N <br />Iz �� <br />ING DATE <br />ING DATEWEE <br />❑ ASSIGNMENT COMPLETED 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 />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />z'30 <br />1/2, <br />Z'3 <br />) 1Z <br />� <br />iL! <br />•3 <br />Z.3a <br />'I Z <br />FOR OFFICE USE ONLY <br />�G. HOURS O.T. HOURS r' <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 ny work related injuries were reported to Selectemp <br />at the time of in' .See reverse for further information. <br />X _ <br />Signature of Empf6yee <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 certify that the above hours are correct. <br />,X -.;� - �- C <br />Signature of Supervisor <br />)T(11 /TAL TOTAL `� / / O ' <br />Hours to nearest quarter hour. "7 Title '/ Date / / <br />CUSTOMER COPY <br />