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" )) SE e4' <br />EMDL0YMENT-SERVI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />EMPLOYEE NA <br />2c/ r t /77/9 vim- 1 <br />SOCIAL SECURITY NUMBER <br />C CO jyl PA � � E ..� <br />60B %E NAME AND/ R PO #AND/ R PO# <br />/ 2 / WE K 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 />*Sunday <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 />V <br />11 2 <br />� <br />lY <br />� �� <br />I�C/ <br />✓ <br />2 <br />r <br />FOR OFFICE USE ONLY <br />G. 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 related injuries were reported to Selectemp <br />at the time of injury. See reverse for further information. <br />X <br />Signature -df Ern o*ee <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 cart! that the above ho are correct. <br />X <br />si of Superyis r <br />TOTAL TOTAL , <br />/ <br />' <br />Hours to nearest quarter hour. � <br />Title Date ` <br />CUSTOMER COPY <br />