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) <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />Of CACC OOIAIT - <br />EMPLOYEE NAME <br />- PA O <br />SOCIAL SECURITY NUMBER <br />COMP A Y N E <br />JOBSITE NAME AND /OR.PO# <br />WEEK ENDING DATE <br />-Zv- 20 1/ <br />0 ASSIGNMENT COMPLETED RETURNING NEXT WEEK' <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />Y IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />• <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 />HOURS <br />OVERTIME <br />HOURS <br />(� <br />2.?p <br />S <br />0 <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 />representati ve Iso, any work related injuries were reported to Selectemp <br />at the time nj .See rev for r. information. <br />X . <br />Signature ofVmRioyee - <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requ a settlement. See reverse for further information. I <br />hereby c thattlie ab e:b s are correct. <br />X <br />Si - ure of S / ervis <br />� TOTAL <br />Hours to nearest quarter hour. III' <br />Title Date <br />CUSTOMER COPY <br />