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- S.EL - E(TEMP t: Sunds <br />EMDL0Y;MENT SERV1(ES <br />P.O. Box 71250 • Eugene, OR 97401 Mond <br />PLEASE PRINT <br />PLO, EE NAME <br />'Q ii �GI " " <br />SOCIAL SECURITY NUMBER . . <br />?CKlc. =Kx= SZ�S� <br />r CWPANY NAME <br />SITE NAME AND /OR PO# <br />WEEK ENDING DATE <br />0 ASSIGNMENT COMPLETED ETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ Y IF YES, NOTIFY SELECTEMP IMMEDIATELY. `. <br />0 .. <br />Tuesday. <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 />�{ AA <br />12 lo <br />12 � <br />.r <br />FOR OFFICE USE ONLY <br />OUR 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 reported to Selectemp <br />At the time of See rev a or further information. - <br />S ignature ff Employee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requires asettlement. See reverse for further information. I <br />her Ay that the above ho reerec rrect. - <br />X <br />S ature of Su i or \ -� <br />Hours to nearest quarter hour.�.J - --VV • . J <br />Title Date <br />CUSTOMER COPY <br />