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ELE(T <br />EM•DL'OYMENT SERVICES <br />P.O. Box 71250.• Eugene, OR 97401 <br />DI CAC= DDIMT <br />EMPLOYE NA ' <br />G � � ME <br />SOCIAL L SECURITY NUMBER .NUMBER <br />1 COMPANY N / AME <br />C l L7 L � <br />JOB ITE NAME AND /OR O# <br />WEEK ENDING DATE <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 />t <br />. <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 />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 inform <br />Signature of Emplo <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- certit at the abov - are correct. <br />-',� <br />gnatureof.$upervrn r - <br />TOTAL TOTAL g .f� / . <br />Hours to nearest quarter hour. 4 <br />y�( Title • t D to / <br />CUSTOMER COPY <br />