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"'­* SELE(TE - MP <br />EMPLOYMENT S ERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI FASF PRINT <br />EMPLOYEE NA <br />v"j G✓ r f S <br />SOCIAL SECURITY NUMBER <br />C9MPAN�AME <br />I O (�� -{ e <br />JOBSITE. NAME AN OR PO# <br />La« � <br />WEEK. NDING DATE .' <br />71 I. <br />❑ ASSIGNMENT COMPLETED / 45RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF.YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />OL 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 />2 !3 - 10 <br />'IL <br />t <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 work related injuries were reported to Selectemp <br />at the time of reverse for further information. .. <br />X � <br />Signature of Em¢royee <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 c e-ebovxhours are correct. <br />Si ure of Supervisor . <br />TOTAL TOTAL <br />Lect11. /D / <?UI► <br />Hours to nearest quarter hour. If 0 . <br />1 Title Date <br />CUSTOMER COPY <br />