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�. ,SELEC " Sunday <br />EMPL0YMENT.SERVI( ES <br />FO. Box 71250 • Eugene, OR 97401 Monday <br />PI FOGF PRINT <br />EM NAM <br />L ��� v` ' <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />JOBSITE NAME AND /OR PO# <br />WEEK ENDING DATE <br />5 -, i. . <br />ASSIGNMENT COMPLETED ®'RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />0 YES , IF YES,.NOTIFY SELECTEMP IMMEDIATELY. <br />NO a . <br />Tuesday <br />.Wednesday <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />REG <br />OVERTIME <br />LUNCH <br />HOURS <br />HOURS <br />C 'a) <br />lU <br />r <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 by an authorized <br />representative_Alsa✓ work related injuries were reported to Selectemp <br />. at the,timr o injury. See reverse for further in�raati�• <br />r <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 />S ignature of Supervisor <br />. DOTAL TOTAL /f-- •!.•�`� t C C.�°'! ( CC U S . ( I <br />Hours to nearest quarter hour. <br />Title Date, <br />CUSTOMER COPY <br />