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SELE(TE�Mp' <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI FACF PRINT <br />EMPLOY NAM <br />1ti v� C <br />O IAL• SECU RITY.NUMBER <br />MPANY NAME. <br />( <br />JOBSITE NAME AND/OWPO# <br />WEEK ENDING DATE <br />8- t - 3 - I � { <br />❑ ASSIGNMENT COMPLETED ICJ RETURNING_NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />DYES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />Sunday <br />Monday <br />Tuesday <br />Wei nesday <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />o <br />7.5' <br />FOR OFFICE USE ONLY " <br />G: HOURS O.T. HOURS <br />EMPLOYEE <br />I certify that the hours 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 reported to Selectemp . <br />at the - time off injury. See reverse for further information. <br />X <br />Signature of Employee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />payroll a settlement. See reverse for further information. I <br />hereb that the s are correct. <br />Si ure of p rvisor. . <br />TOTAL TOTAL --- <br />\/u \ I — I S — + .� <br />Hours to nearest quarter hour. ' ` J <br />Title _ Date <br />CUSTOMER.COPY <br />