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i, .. <br />EMPLOYMENT SERVICES <br />P.O. Box 71250. • Eugene, OR 97401 <br />DI FACE DRIAIT <br />EMPLO E NA E <br />SOCIAL SECURITY NUt)A� n <br />C Wfi-ANY AIAME <br />I <br />JOBSITE NAME AN[V R PO# <br />Oe e j D / <br />❑. ASSIGNMENT COMPLETED ETURNING NEXT WEEK <br />HAVE YOU HAD ANON THE JOB INJURY THIS WEEK? <br />❑ YE_ YES, NOTIFY SELECTEMP IMMEDIATELY. <br />O <br />� '•v <br />day <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 />f <br />l k ' 00 <br />A/# /f1 <br />;r/ ' <br />Vi to <br />el <br />�l <br />yjD <br />; <br />r <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. o, any work related in' ies were reported to Selectemp' . <br />art he ti ry. Seer a se for f infornfatigrig. <br />Signature of Employee _ <br />CLIENT <br />We realize that to transfer one of•Selectemp's employees -to our <br />uires'a s e reverse for further information. I <br />he eby c . � th he above hours a correct. - <br />ft <br />S , ature of S <br />TOTAL TOTAL <br />Hours to nearest quarter hour. a/D 1 .11 <br />Title Date <br />CUSTOMER COPY <br />