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EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER <br />i <br />/ COMPANY NAME <br />'J J NAME AND /OR PO# <br />/Ypt�r�/ <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />Onday <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 />FOR'OFFICE USE ONLY <br />OURS <br />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 py an authorized <br />representative.. Also, any work related injuries were re peed to Selectemp <br />at the time of injury. See reverse for further informa <br />X <br />Signature o ,mployee <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requires a s t. See reverse for further information. I <br />hereb certdy t e above rs are correct. <br />J <br />X' <br />Suture of Supdrvi or <br />TO L , TOT /� // _ 2/ // <br />Hours to nearest quarter hour. / <br />l/V G Title Date <br />