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- MP <br />- E'LE(TE <br />E M P L 0 Y M E ' N T S E R V I C E S <br />P.O. Box 71250 • Eugene, OR 97401 <br />01 PACIP 001flKIT <br />4 - - <br />Sunday <br />Monday <br />Tuesday <br />-EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />C A_ <br />__JOBSITE NAME AND/OR PO# <br />WEEK ENDING <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 />- E] NO <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 />J.) <br />6 <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 />representative. Also, any work related injuries were r _rted to Selectemp <br />at the time of injury. See reverse for further inform n. <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. 1 <br />_beieby ce <br />fify that theme Bare orrect.* <br />nature of Su <br />"I <br />TOTAL c <br />Hours to nearest quarter hour. <br />Title Date <br />CUSTOMER COPY <br />