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i <br />m j <br />EMPLOYMENT . 5 ERV10ES <br />P.O. BOX 71250 Eugene, OR 97401 <br />PI FASF PRINT _ <br />EMPLOYE AME <br />-to <br />SOCIAL SECURITY <br />M'& <br />JOBSITE NAME AND /O O #. <br />Ay W K NDING D j <br />ly- <br />ASSIGNMENT COMPLETED OMPLETED j RETURNING NEXT WEEK <br />V N E YOUHAD ANON THE JOB INJURY THIS WEEK? <br />IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />funday <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 />/ <br />1 <br />Ajo <br />A f <br />FOR OFFICE USE ONLY <br />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 worlyrelated injuries were re rted to Selectemp <br />at the time pr j .See re se for t rt i6formati <br />X <br />Signature of Employee <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 . certify that the above hours are correct.' <br />Signature of Supervisor <br />/� TOTAL TOTAL' <br />Hours to nearest quarter hour. ' <br />Title Date <br />CUSTOMER COPY <br />