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'SELE(TEMP <br />s <br />E.MP1.0YMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI�FAAF PRINT <br />EMPLOYEE NAME <br />SOCTAL SECURITY NUMBER <br />COMPANY NAME <br />JOBSITE NAME AN R_ PO# <br />WEEK ENDING DATE <br />❑ ASSI G NMENT COMPLETED ❑ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />El . 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 />Hours to nearest quarter hour. 16, <br />Title <br />Date <br />3. <br />6,36, <br />'!5` <br />FOR OFFICE USE ONLY. <br />G. 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 byy. an authorized <br />representative. Also, any work related injuries were repo t €d to Selectemp <br />at the time of injury for further informatio <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 />. here ti . that the abov re correct. <br />Si ture of Su ervisor <br />CUSTOMER COPY' <br />TOTAL <br />TOTAL <br />Hours to nearest quarter hour. 16, <br />Title <br />Date <br />CUSTOMER COPY' <br />