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,' <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />! e Sunday <br />i <br />r . <br />Monday <br />EMPL YEENAME <br />SOCIAL SECURITY NUMBER.- <br />COMPANY NAME <br />JOBSITE NAME AND /OR PO# <br />T r 'a- J41 <br />WEEK ENDING DATE <br />ASSIGNMENT COMPLETED,' D RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP, <br />LESS <br />LUNCH <br />IREG <br />HOURS <br />OVERTIME <br />HOURS <br />Hours to nearest quarter hour. <br />TOTAL TOTAL <br />1UG <br />CUSTOMER COPY <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 o y an authorized <br />representative. Also, any, work related injuries were r rted to Selectemp <br />at the time of injury. See reverse for further infor on. <br />X / <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 hours are correct. <br />X <br />ignature of Su ervisor `- <br />Title Date . <br />