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zLE(T <br />E -EMP <br />EMDL0YMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI FAC17 DDIMT <br />EMPLOYEE N ME . <br />SOC SECURITY NUMBER <br />C PANY N E <br />O k <br />OBSITE NAME AND /OR P <br />WEE <br />ENDING DATE <br />I <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ ES 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 />. 3,D " <br />Z',j <br />3 <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 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 mf anon. <br />�� <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 qe /tify that ft,�urs are correct. , - .. - <br />X nature A. <br />of Supervis r <br />TqT L . .T <br />Hours to nearest quarter hour. t y / ^ v � . <br />Title Date . <br />CUSTOMER COPY <br />