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L <br />MDCOYM:ENT SE.RVI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIAIT <br />EMP OYEENAME <br />C Y P`Q l C 9 <br />OCIAL SECURITY NUMBER <br />C. <br />COMPANY NAME <br />c L I— ix��e— <br />. k <br />JOBSIT •NAME AND/ 6R PO# <br />WEEK E DING DATE <br />❑ ASSIGNMENT COMPLETED. YJ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? ., <br />❑ YES IF. YES, NOTIFY SELECTEMP IMMEDIATELY.. <br />❑ NO <br />kl euniiay <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 />23 <br />Hours to nearest q <br />uarter hour. <br />Signature of Employee <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 certify that the, ou ours are correct. ' <br />X� <br />Signature of Supervisor c/�y <br />TOTAL <br />3Z TOTAL <br />Title Date <br />CUSTOMER COPY <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 ntiy an authorized <br />representative. Also, any work related injuries were rgoorted to Selectemp <br />at the time of injury. See reverse for further inform n. - <br />X <br />