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S <br />, � SE.'LE(TEMP. <br />f <br />EMPLOYMENT SERVICES <br />P.O: Box 71250 • Eugene, OR 97401 <br />DI CACC DDIMT <br />WPLOYEE NAME <br />SOCIAL SECURITY N13MBER . <br />C p�1PANY NAME <br />JOBS TE NAME AND /OR PO# <br />Zo <br />WEE BRING, 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 />W'day <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 />70 <br />5 3D <br />Z3v <br />3 <br />1L/ <br />Z � <br />30 <br />y <br />r�x �rricr; usr. ONLY <br />- G. HOURS O.T. HOURS, <br />4 .. <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 on authorized <br />representative. Also, any work related injuries were reported to Selectemp <br />at the time o pje See reverse for further information. , <br />Signatu o Employee <br />a ' . CLIENT <br />We realize that,�to'transfer one.of- Selectemp's employees to our , <br />payroll.req Tres ei.settlement. See reverse for further information. I <br />at ify that the a4avaliotjgs are correct: <br />X" <br />gnature of Su ervi or I <br />TOTAL TOTAL <br />Hours to nearest quarter hour. <br />Title Date - <br />CUSTOMER COPY <br />