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E M P L O Y M E N T S E R V I C E S <br />P.O. Box 71250 • Eugene, OR 97401 <br />\ Ounday <br />Monday <br />"Tuesday <br />W ednesday <br />Thursday <br />-EMPLOYEE*NAME- <br />ITY NQ BER' <br />'"IAL'StCUR <br />80 <br />..-''COMPANY NAN , <br />r9 <br />JOBSLTE NAME AND/OR POD <br />WEEK 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 />Friday <br />Saturday <br />" ' START' <br />STOP - - <br />, ESq <br />� <br />I? LJN6H <br />H OURS <br />HOURS <br />OVERTIME <br />1106FIS <br />4.00 <br />6'-�o <br />" <br />to <br />Hours to nearest quarter hour. <br />TOTAL <br />�0 <br />TOTAL <br />FOR OFFICE USE ONLY <br />G. HOURS O.T. HOURS <br />EMPLOYEE <br />I"rt%, In howlshown wese r , m, o t o t al aut h orized <br />the 'c <br />t '� <br />week, h t�.wa <br />".party vg "'h. client on, <br />I) _ed <br />repr69b'6tatid6.'Als6any work related were reported toselecte <br />at the <br />, I"e e r . 1 i. —, % -�-! <br />t f S fq th r '9f',m�atmn. <br />eg,ens r, ur <br />4, <br />gnaturE <br />C LIENT <br />We realize that to transfer one of 9ef6cte4's employesis io-06 <br />'g yroll requires a settlement. See reverse for further information: I I <br />hereby certify that the above - hours 'are correct. <br />X <br />Signature of Supervisor <br />.4 91 — <br />Title Date <br />CUSTOMER COPY <br />