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..SELE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 Eugene, OR 97401 <br />PI FGSF PRINT <br />EMPLOY <br />Q tti VI & CA r i <br />OCIAL SECURITY NUMBER <br />G� CQMPANY�IAME <br />D " I 1 . [ <br />JOBSITE NAME AND /OR O# <br />i <br />WEEK ENDING DATE <br />❑ ASSIGNMENT COMPLETED KRETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO i <br />Sunday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />Friday <br />Saturday <br />... <br />, RUG <br />START <br />STOP_ <br />LESS <br />LUNCH <br />HOUR <br /></ <br />`^ <br />Z; 3v <br />. <br />` <br />30 <br />y <br />'^ <br />p <br />'Hours to nearest quarter hour. <br />OVERTIME . •- FOR OFFICE USE ONLY <br />S HOURS REG.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 work related injuries were reported to Selectemp: <br />at the time aLinjury. See reverse for furth formatio .. <br />Signature of Employee - <br />CLIEN I <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 Supeerrviso / (y <br />-TOTAL �.♦ /�• /// / / — I / '��.� <br />Title Date <br />CUSTOMER COPY <br />