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"S <br />EMDLAYMENT SE.RVI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIKIT <br />Sunday <br />Monday <br />EMPLOYEE NAME <br />0. V1 <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />C 1A W "e <br />JOB ITE AND /OR POW <br />W • ENDING DATE <br />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 />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 />)! <br />30 <br />, <br />Z <br />30 <br />23v <br />3v <br />� <br />6. <br />23o <br />Hours to nearest quarter hour. <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 retate6'rnjuries'were reported to Selectemp <br />at the timQ See revfor further information. . <br />-Signature Employee /ss <br />CLIENT <br />We realize.that to transfer one of Selectemp's employees to our _ <br />payroll'requir s'a settlement. See reverseYor further information. 1 <br />hereb c rtif that the above rszre correct. <br />Y � <br />X. <br />Si ure of Suup /ervi r, <br />TOT�A^L�) � TOTAL fi <br />l�c =( <br />CUSTOMER COPY f <br />