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SELE(T�EMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />DI CACC DDIh17 <br />EMPLOYEE NAME <br />SOCIAL SECURITY NUMBER <br />i <br />i <br />COMPANY; NAME <br />f-y <br />JOB ITE NAME A D /OR PO# <br />rte, �-.� <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 />Su'nO <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 />z.7 <br />FOR OFFICE USE ONLY <br />REG. S 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 an authorzed <br />representative:, Also, any work related injuries were r "led to Selectemp <br />at the time of i Ijury. See reverse for further infor <br />X C� -�'_. <br />Signature of Emplov� <br />CLIENT . <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requir�'s a settle ee reverse for further information. I . <br />her certi that the fibove hoursIt correct. <br />X <br />Si pa ure of Supervisor <br />TO TAL TOTAL - i / (. � �- 01 ./ <br />Hours to nearest quarter_ hour.. 2 Title. Date . <br />CUSTOMER,COPY <br />