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r ( <br />EMDL0YMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI FACE PRINT <br />EMPLOYE NAME <br />SbdAL SECURITY NUMBER <br />I <br />COMPANY NAME <br />JOBSITE NAME AND /OR PO# <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED RETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />.� NO ! <br />Onday <br />Monday <br />Tuesday <br />Wednesday <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 of injury: See reverse for further information. <br />— 1 11 �y <br />Signature of Employee <br />Thursday <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />Friday. payroll requir s tree 'Irr'er. See reverse for further information. I <br />hereby 19 th the above hl ur re coriect. <br />Saturday X ' <br />Si u re of Supe isor t/ <br />TOTAL TOTAL � I C2y/ / J� j <br />Hours to nearest quarter hour. a Title Date <br />CUSTOMER COPY <br />',.,. <br />START STOP LESS REG OVERTIME <br />LUNCH HOURS HOURS <br />LO '0 <br />Co 2:30 30 `6 <br />(V <br />FOR OFFICE USE ONLY <br />OURS O.T. HOURS <br />Z; 30 <br />3 0 <br />8 <br />FOR OFFICE USE ONLY <br />OURS O.T. HOURS <br />