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:..'- S ELE(TEMP <br />EMPLOYMENT SERVICES <br />.0b. Box 71250 • Eugene, OR 97401 <br />..DI CA CC DDIAIT <br />EMPLOYEE N <br />/ ,Lr;.• G,/ <br />SOCIAL SECURITY NUMBER <br />MPANY NAME <br />JOBSITE NAME AND /OR PO# <br />S) ( , WO )y <br />EEK 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 />unday <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 />Z30 <br />FOR OFFICE USE ONLY <br />HOURS O.T. HOURS <br />EMPLOYEE <br />I certify that the hours shown represent my totaf 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 information. ' <br />Signatufe of Employee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requi es a. settlement: See reverse for further information. I <br />hereby ce ti that the are correct. <br />re of u ervisor <br />TOTAL TOTAL <br />Hours to nearest quarter hour. V lK <br />((( Title Date <br />CUSTOMER UIPY <br />