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ti. <br />EMPLOYMENT S.ERYI(ES <br />P.O. Box 71250 • `Eugene, OR'9740f•r' <br />PI FASF:PRINT <br />'Sunday <br />J . <br />Monday <br />, <br />EMr 5 LOYEL ' Isl AME <br />SOCIAL SECURITY NUMBER <br />C PANY NAME <br />JO A D /OR PO# <br />J G l <br />WEEK ENDING DATE <br />❑ 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 />Tuesday' <br />Wednesday <br />r <br />Thur <br />Friday <br />I . <br />Saturday <br />a <br />3 <br />i <br />START` <br />STOP <br />LESS <br />LUNCH <br />'•=REG <br />HOURS <br />OVERTIME <br />HOURS <br />(� L>D <br />2;30 <br />3v <br />A+1.t ..,, <br />tMfh . <br />t' <br />�, <br />yittn. <br />FOR OFFICE'USE ONLY <br />EG. HOURS - O.T. <br />EMPLOYEE <br />I. certdythat the hours shown represent mytotal hours duririg the <br />week, and that they.were, properly verified'by,the clientof byan Authorized <br />repr ?sentahve. ;any work (elated mluries" yere reported to $electemp <br />at time of tnlury See reversetor further mformahon a <br />o <br />S Signatufe of Employees , 4' <br />CLIENT? - � <br />We reallze" that fo transfer,dhe of.Selecternps,employees I' our <br />payroll requires 'a settlement. See revefse for further mf ation I - <br />hereby certify that the above hours are correct <br />e„ <br />X ---9` <br />S�ture of Su eivisor <br />TOTAL TOTAL <br />• Hours to nearest quarter hour. , _ . . <br />Title Date <br />CUSTOMER COPY <br />