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?i SELE(TEMP <br />EMDL0YMENT� SERVICES <br />P.O. Box 71250• Eugene, OR 97401 <br />DI FACE PRINT <br />1 0"day <br />Monday <br />{J <br />EMPLOYEE NfArE . <br />SOCIAL SECURITY NUMBER <br />CrPAN NAME <br />AM �C_ <br />JOB ITNAME AND/OA PO# <br />1 1 WEEK ENDING DATE . <br />I �t <br />❑ ASSIGNMENT COMPLETED TURNING 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 />Thursday <br />Friday <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />k �Z <br />Z t3 <br />BI Z <br />'30 <br />14 <br />: FOR OFFICE USE ONLY <br />OURS OT.HOURS <br />EMPLOYEE <br />I certify that the hours shown represent my total hours worked during the <br />week, and that they were propeely verified by the client or by an authorized' <br />.representative. Also, any work related injuries were reported to Selectemp <br />at the time of injury. See reverse for further information. . <br />Signature of Empt5y e . <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 cerr hat,the bove hours are correct. ' <br />Si ttfre of upe , isor <br />JpTA� TOTAL �! J`� <br />Hours to nearest quarter hour. <br />Title -Date <br />CUSTOMER COPY , <br />