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'SELE(TEMP <br />E M P L 0 Y M E NIT S E R V I C E S <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIAIT- <br />�MPx NAME� <br />SOCIAL SECURITY t�U� <br />v // <br />�WPANY Ii I <br />JOBSITE NAME AND% PO PO# lv// <br />/e E K ENAT /' f <br />❑ ASSIGNMENT COMPLETED ETURNING NEX WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />O ES IF ES, NOTIFY SELECTEMP IMMEDIATELY. <br />�nday <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 ' 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 w k related injuries were rep ad to Selectemp <br />at the ti 8ee.r rse for f r informati <br />X' <br />Signature of Employee . <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />�paylot qui a 'ettlement.- reverse for further information. I <br />' hereby that the above hours - are correct. <br />X <br />Signature of Supe is& \ / �7 <br />,3Q7AL TOTAL <br />He to nearest quarter, hour. <br />Title Date <br />CUSTOMER COPY <br />