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i r <br />r <br />ELE( <br />4 E.,M . ,PILOYMENT 1 5ERVI(E5 <br />P.b.'Box 71250 • Eugene, OR 97401' <br />PI FASF PRINT <br />• <br />Sunday <br />Monday <br />• <br />..i�'f,,; <br />�r] <br />- <br />V;h ., <br />: �- <br />USE�OD <br />FOR OFFICE L <br />f , OURS - O.T. HOURS <br />START <br />STOP <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />.HOURS <br />r/ U <br />.f <br />.10 <br />EMPLOYEE <br />r <br />p� / '• Q /� <br />h ignature of Empl e <br />EMPLOYEE NAME <br />SOCIAL.SLCURITY'NUMpER <br />' COMPANY NAME � " r <br />C � U/ �✓� Cl+ti , <br />JOBSIT NAME AND /OR PO# <br />169101 "I'Stvf1l a /mod <br />WEEKENDING DATE . <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />11 YFS IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />C NO <br />Tuesday <br />- <br />Wednesday. <br />• <br />..i�'f,,; <br />�r] <br />- <br />V;h ., <br />: �- <br />I certify that the•hours. shown represenl.my. total. hours worked during,thea <br />week;and that they were'properly venfiedby'the cliehforby.anauthorized,'• <br />representative Also; any work related mlunes werereported to Selectemp ' <br />at the'time of i njury See reverse for further information -. <br />< <br />j � <br />3a: <br />• <br />30 s .. <br />r/ U <br />.f <br />�/ /�, y <br />r <br />p� / '• Q /� <br />h ignature of Empl e <br />;Thursday <br />:CLIENT. < <br />1 F <br />. �.., l 3 <br />' We realize thet.to transfer one of Selectemps_employees'to'our <br />payroll'regt1Tres a settlement: See. *reverse for further information I Z <br />Friday. <br />.hereb c r Sfy that the abov orrecL <br />X <br />Saturday <br />- <br />TOTAL <br />(/,/ / 1 - ) . <br />L <br />U <br />Sign re of Supervis r <br />Hours to nearest quarter hour. <br />Title Date <br />9 <� C <br />CUSTOMER COPY <br />