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S-E.LE(TEM�P *nday <br />EMPLOYMENT IE.RY1`CE$ <br />P.O. Box 71250 s Eugene, OR'97401 Monday <br />PLEASE PRINT. t <br />EMPLO ENAME <br />SOCIAL SECURITY NUMBER <br />�, S S -• <br />i COMPANY NAME <br />s: <br />JOBSITE NAME.AND /OR PO# .. <br />WEEK ENDING DATE <br />ASSIGNMENT COMPLETED ❑ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />DCN <br />Tuesday <br />Wednesday <br />n <br />•,Thursday <br />Friday. <br />Saturday <br />STARTS <br />STOP <br />• <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />•A. <br />t <br />.0, <br />nA O. <br />/+ 0' <br />30. <br />:� t-•• <br />, <br />t <br />14 3U <br />3° <br />j'. <br />representative Also; any work related injuries were reported to Seledtemp <br />at the ti a of Infury'See rev s�fo ff thecinformationJ <br />X <br />CLIENT' _. <br />We realize that to transfer one of Sel'ectemp's employees to ,our4 <br />payroll requires a settlement..See reverse for'further information 17, <br />hereby certify'that the above hours are correct. - . <br />X <br />ignature of Supervisor <br />TOTAL TOTAL <br />Hours tonearest quarter hour. O <br />. Title Date • <br />CUSTOMER COPY ., <br />