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SELE(T.EMP.' <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br /> ' DIFACF PRINT ' <br />Onday <br />Monday <br />>: EMPLOYEE NAME . <br />OCIAL SECURITY NUMBER <br />COMPANY NAME <br />e <br />JOBS TE NAME A D /OR PO# <br />f r rf i C <br />WEEK ENDI G DATE <br />l0 _ 2 l7 <br />El 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 />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 />;ji <br />2 <br />, <br />6: oo <br />Z:3 <br />. S <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, arid. that they were properly verified by the client or by an authorized <br />representative.'Also,.any work related injuries were repo ed.to Selectemp <br />at the time ofinjury. See reverse for further informa <br />X <br />Signature of Emplo - <br />CLIENT . <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requires a settlement. See reverse for further infor tiori. l <br />hereby certify that the above hours are correct. <br />Signature of S pervisor <br />TOTAL .TOTAL <br />Hours to nearest quarter hour. �(' ( / <br />v Title f - Date'. <br />CUSTOMER COPY <br />