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SE.LE(TEMP <br />EMIf L0YMENT.SERVI(ES <br />P.O..'Box 71250:• Eugene, OR 97.401 <br />PI ll PRINT . <br />EMPLOY E <br />C .� � � NAME <br />+�Iso <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME N <br />JOBBSITE NAME AND /OR P6# <br />WEEK ENDING DATE <br />3 <br />-12 I/ <br />El. ASSIGNMENT COMPLETED. &TRETURNINGNEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />o <br />Sunday <br />Monday <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 />J'J <br />Hours to nearest quarter hour.. <br />CUSTOMER COPY <br />ANIL FOR OFFICE USE ONLY <br />OURS. 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 rep ted to Selectemp <br />at the time of injury. See reverse for further informali <br />x C' cc . <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. I <br />hereby certify that the above s are correct. . <br />r <br />Si gnat 4e of Supervisor 1 _ <br />Title Date <br />