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SEL'E(TEMP <br />E M P L O Y M E N T S E R V I C E S <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI F:ACZF PRINT <br />EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER <br />COM PANY NAM r <br />j <br />OBqI;T <br />EN�,ME <br />d ;fo s e. ve <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED [P NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YPS' IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />P <br />Runday <br />Monday <br />Tuesday <br />Wednesday <br />aT <br />T hursday <br />Fuda <br />START <br />STOP <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />�a <br />0 <br />VIT <br />.3, <br />`41 <br />Hours to nearest quarter hour- <br />CUSTOMER COPY. <br />FOR USE ONLY <br />HOURS <br />O.T. HOURS <br />�a <br />0 <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 ti5pAinju ry. Se e reverse for further information <br />gnature of A <br />Y. <br />IENT <br />Y" <br />L- <br />' - -'!" � " e' r <br />-. at t t�rar tQ'ou <br />hereby� ify that the : re correct I" <br />�cq that <br />!A: <br />Si gna tu re ' of Supervis o\ il�— <br />Title Date <br />