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i <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI FACE PRINT <br />EMPL N ME <br />Go✓t /(j'e JS2 <br />OCIAL SECURITY NUMBER <br />r COMPANY NAME <br />JOB ITE NAME ND /OR PO #. <br />�r CA / C.. <br />WEEK ENDING DATE' <br />❑ ASSIGNMENT COMPLETED eRETURNING 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 />L ) <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 ' nt or by an authorized <br />representative. Also, any work related injuries re reported - to Selectemp <br />at the time eo of f injury �See �reverse for further i rmation. <br />X CC/ �(�S - .- <br />Signature of Emplo <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 />h that are correct. <br />ature of Supervisor <br />TOTAL TOTAL <br />Hours to nearest quarter hour. t / <br />Title Date <br />CUSTOMER COPY <br />