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y..i / �SELE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI FACF DRINT <br />•Sunday <br />Monday <br />' EMPLOY NA E <br />SO L S CURITY,NUMB <br />COMPANY AM ? ; <br />xi { t <br />JO ITE:fVA AN /O Q #' <br />s r It <br />WEEK ENDING'DATE <br />❑ASSIGNMENTCOMPLETED TURNING NEXT WEEK <br />L HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />O YES IF YES,.NOTIFY SELECTEMP IMMEDIATELY , <br />Tuesday <br />• r . <br />Wednesday <br />r * <br />J <br />'Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />REG: <br />HOURS <br />OVERTIME <br />HOURS <br />f <br />�i <br />01 <br />-. <br />. - <br />•�'� <br />`�.. /, <br />VIHL V <br />Hours to nearest quarter hour._ �— <br />TOR.O 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 />rep`r'esentative..Al So, .any work related injuries were reported tozSelectemp <br />at the time of Injur ,See revs - for further infor on ; `.L• py <br />X '•, may$ 3 <br />a <br />.z' � , 3 '� CLIENTS:. r �F✓ <br />We realize that to tLans(er one of Seledtempsemployees to our r <br />payroll requires a. settlement.' Ses revers for further fpformation 1 <br />hereby certlty that'the above hours aie ciirregf �• s '. <br />�. <br />X. - <br />Sig` Are of Supervis I <br />• w r� <br />CUSTOMER COPY <br />