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-MP <br />,EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI PACE DMINT <br />EMP NAME <br />SOCIA EC RI NUMBER <br />COMPANY A <br />ME- <br />�J I�� / AND /OR PO# <br />WEEK ENDING DATE <br />Q, ASSIGNMENT COMPLETED ' ❑ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <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 />.b <br />2 3D <br />FOR OFFICE USE ONLY' <br />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, gQy work related injuries were reported to Selectemp <br />. at the tim �njury. a rever rturther information. <br />Signature 'IV pl yee <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 q✓?rhfy that the above hours, are correct.. <br />ignature of 5upervisp <br />. ' TOTAL TOTAL <br />Hours to nearest quarter. hour. <br />Title Date <br />