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. <br />EMD.L0YMENT SE.R.VI( E.S <br />P.O. Box 71250 •. Eugene, OR 97401 <br />DI =ACC DDINT ` <br />*Sunday <br />Monday <br />EMPL EE ME <br />1. (�H V►S L) S' <br />SOCIAL SECURITY NUMBER <br />n C MPAP� NAME <br />o <br />JOBSITE NAME AND /OR PO# <br />�W.EEI$JPDING DATE <br />❑ ASSIGNMENT C RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ F IF .YES, NOTIFY SELECTEMP IMMEDIATELY. <br />RrN <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 />3o <br />. <br />X15 <br />a ; 3 <br />�.7 <br />FOR OFFICE USE ONLY <br />G. HOURS O.T. HOURS: <br />EMPLOYEE <br />I certify that the hours shown represent my total hours worke the <br />week, and that they were properly verified by the client or byaa�iffauthorized <br />representative. Also, any work related. inj r s were reported'{o Selectemp <br />at the time of inlur ee reverse for furl r riformatio l <br />X . <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 certify that the above hours are correct. <br />X 9- j <br />Signature of Supervisor <br />TOTAL TOTAL <br />Hours to nearest quarter hour. . <br />Title Date <br />CUSTOMER COPY . <br />