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* •Sunday <br />EMDL04MENT SEH "VICES <br />P.O. Box • Eugene, OR 97401 a Monday <br />PLEASE PRINT <br />-E OYEE ME <br />4 <br />CCI S } Y'NUMBER z � <br />h 1. <br />C PANY NAME <br />JOBSITE NAME AND /OR PO# <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />[�>,ES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />LJ NO <br />P. Tuesday <br />Wednesday <br />?hursda- <br />Friday <br />4 � Saturday <br />; START <br />.jSTOP <br />LESS <br />LUNCH <br />REG <br />HOURS. <br />OVERTIME <br />HOURS <br />3 <br />FOR OFFICE' USE ONLY' <br />-G. H URS O.T. HOURS <br />v <br />EMPLOYEE <br />I certify -that the hours shown represent mg total hours worked during the <br />week and Shat they /were propeily ven1Zd : by the client Z..by an adQrized - <br />representatw Also, any work injufies were. reported to Selectemp <br />aI the o I ry.See revers ° r further formation J - <br />� / <br />f <br />gha,i&e of Empldyee <br />CLIENT <br />"We realize that.to.transter one of Selectemp§_employees to our ` <br />' payroll requires.asettlement. See reverse for further SnformaGon: I - <br />hereby certify that the above hours are correct <br />7 <br />.Signature of Supervisor <br />. ­ � — �: I <br />Hours to nearest quarter hour. <br />Title Date <br />CUSTOMER COPY <br />