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E M P L O Y M E N T S E R V I C E S <br />P.O.. Box 71250 • Eugene, OR 97401 <br />01 I=ACZF= PRINT <br />Ou n d a'y <br />r <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />EMPLOYEE NAME <br />1;CLA Cao✓ . <br />I SOCIAL SECURITY NUMBER <br />_ - 2 K <br />- COMPANY NAME <br />C 4P_ A Ir_ <br />JQ SI T ONA ME AND/OR.PO# <br />, V <br />WEEK ENDING DATE <br />❑ ASSIGNMENT C . OMPLETED, RETURNI NEXT WEEK <br />HAVE YOU HAD AN.ON THE JOB INJURY THIS WEEK? <br />k . <br />QYES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />?N—NO <br />START' <br />:STOP <br />LESS <br />LUNCH <br />- REG <br />HOURS <br />OVERTIME <br />HOURS <br />12; <br />3 o <br />1 6 <br />12� <br />. 3Z). <br />FOR OFFICE USE ONLY <br />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 Also, any work tM injuries were reported to Selectemp <br />at See r e 6rse for further information. <br />77 <br />X <br />Signature 4Employee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />pa yroll requires a settlement. See reverse for further information. I <br />hereby iffy that the a 'li correct. <br />aatureof supervis <br />TOTAL TOTAL <br />Hours to nearest quarter hour. Date <br />�j Title CUSTOMER COPY <br />