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* SE LE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIAI'r <br />- EMPLOYE A <br />��,��►S e Mar r� <br />SOCIAL SECURITY NUMBER <br />CCOPANY.NAME <br />` 1 ( L! <br />JOBSITE NAME AND/OR PO# <br />WEEK ENDI G DATE Z. <br />ASSIGNMENT COMPLETED E RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ Y 11` YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />Onday <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 />CJ <br />0 ? , 3C <br />I , <br />'1 <br />OIL <br />� L-A) <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 b the client or by� an' uthorized <br />representative. Also, any work related injur' ,were repo Ed Selectemp <br />at the time of injury. Se verse for furth , ' <br />x <br />Signature of Employee . <br />CLIENT <br />We iealize that to transfer one of Selectemp's employees to our <br />payroll requi es a settlement. See reverse for further information:,) <br />he by. that the e o are correct. <br />Sig ur- of Sup rvi or. <br />.TOTAL TOTAL, <br />Hours to nearest quarter hour. Titl <br />3 t /� tt • ^�-- ��at <br />r e Date <br />CUSTOMER COPY <br />