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\ <br />- 1 <br />4unday <br />EMPLOYMENT SERVICES <br />JOBSITE PO# <br />i <br />P.O. Box 71250 • Eugene,.OR 97401 <br />Monday <br />DI FACE DRIMT <br />HAVE YOU HAD AN ON THE'JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />PLOY AIVIE �� <br />SOCIAL SECURITY( j�l �• <br />O I�1�4N 6q 9 <br />�./�. I <br />JOBSITE PO# <br />i <br />P EEK <br />ENDIN <br />, , <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 />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 />6�► <br />/ <br />fh ►�, <br />f� <br />14 <br />D�i <br />- <br />FOR OFFICE USE ONLY <br />OURS 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 ls0 ny "work related injuries were repo toSelectemp <br />at the time inlur ee reverse rfurther matio <br />f t " <br />X'.. r <br />Signature of Employee <br />CLIENT, <br />We realize that to transfer one of Selectemp's employees to our - <br />payroll requ res a settlement: See reverse for further information.I <br />hereby certify th y , e.hoyrs are correct. <br />�natur.of Sup, visor <br />TOT OTAL f <br />Imo <br />Hours to nearest quarter hour. ., J <br />Title Date <br />CUSTOMER COPY <br />