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i SELE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />EMPLOYE NAME <br />a �G,V" �,e <br />S6dAL SECURITY NUMBER <br />COMPANY <br />JOBSITE NAME AND /OR 06# <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ ES 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 />Lo <br />Z,' <br />3D <br />3D <br />g <br />l <br />FOR OFFICE USE ONLY <br />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. Also, any work related injuries were reported to Selectemp <br />at the time f injury. See reverse for further t1mation. <br />X I. <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 />jereby c fjrI t the above.hour are correct. <br />Signature of Supervisor w <br />TOTAL TOTAL .•.�'� � ,, ,�.f -' �` y l� _ C_ 1' <br />Hours to nearest quarter hour. O lY 6 r C 7 i J <br />Title Date <br />