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LE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CAC= 0971MT <br />PLOY NAME <br />SOC14 SECURITY. NUMBER <br />0 a� <br />� CO AN NAME <br />G� 2 <br />SITE jNAME AND /OR FO# <br />�r VY\ c Vk1 c-"k Cx <br />WEEK ENDING DATE ' <br />r 21, 2.0111 <br />❑ ASSIGNMENT. COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />YES 1F 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 />4 HOURS <br />7 <br />OVERTIME <br />HOURS <br />. �2 <br />3 <br />14 <br />� <br />.' <br />Y►ll n. <br />V <br />�p <br />In <br />FOR OFFICE USE ONLY <br />G. HOURS "O.T. HOURS <br />r <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 informatio <br />x 6 .� .. ter . t <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 <br />Signature of Supervisor <br />H6urs to nearest quarter.hour. <br />Title . Date <br />