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0 rj EM I 1 I At-'^ S <br />SOCIAL SECURITY NUMBER <br />OMP :NAME <br />C. �,�, <br />JOBSITf NAME AND/Oh PO# <br />W END ING DATE <br />❑ ASSIGNMENT COMPLETED ,eRETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YES' IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />.C7 NO <br />Tuesday <br />Wednesday <br />s <br />Thursday <br />Friday <br />Saturday <br />START <br />e sunday <br />LESS <br />LUNCH <br />REG' <br />HOURS <br />EMPLOYMENT SERVI(ES <br />P.O. Box 71250 • Eugene, OR 97401 <br />1 Monday <br />PI FASF PRINT <br />0 rj EM I 1 I At-'^ S <br />SOCIAL SECURITY NUMBER <br />OMP :NAME <br />C. �,�, <br />JOBSITf NAME AND/Oh PO# <br />W END ING DATE <br />❑ ASSIGNMENT COMPLETED ,eRETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YES' IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />.C7 NO <br />Tuesday <br />Wednesday <br />s <br />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />REG' <br />HOURS <br />OVERTIME <br />HOURS <br />7, 7 3J <br />1 (2 <br />2 . 3 <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. Also, any work related injuries were reported to Selectemp <br />at the time time o reverse for further information. - <br />X <br />Signature of Employee <br />CLIENT <br />We realize that to transfer one of Selectemp'a employees to our <br />payroll requires a settlement. See reverse for further Information. I <br />hereby certify that the above hours are rrect. <br />X <br />Signature of Super vi <br />IVIAL IVIAL J � /� � OC ) 7 <br />Hours to nearest quarter hour. © <br />file Date <br />1 <br />CUSTOMER COPY. <br />