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EMPLOYEE NAME . <br />'a � C� <br />SOCIAL SECURITYAUMBER <br />COMPANY—NAME <br />JOB IT E NAME AND /O O# <br />�C. <br />/ WEEK ENDING DATE <br />El 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 />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />• Sunday <br />EMP <br />REG <br />HOURS <br />P.O. Box 71250 • Eugene, OR 97401 <br />Monday <br />DI FACE PRINT <br />EMPLOYEE NAME . <br />'a � C� <br />SOCIAL SECURITYAUMBER <br />COMPANY—NAME <br />JOB IT E NAME AND /O O# <br />�C. <br />/ WEEK ENDING DATE <br />El 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 />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 />9100 <br />6';0 <br />: �O. ' <br />f� <br />1 V IML <br />Hours to nearest quarter hour. �� <br />9t�6 <br />CUSTOMER COPY <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 />t'I <br />at the m of injury. See rever a for further information. <br />X ,Y infoion. . <br />t <br />Signature o: 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 certify that the above hours are correct <br />X. G <br />Signature of Supervisor - <br />Title Date - <br />