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w a, <br />O <br />a <br />SELE(TEMP da y <br />•rl <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 Monday <br />PI F4CF PRINT <br />EMPLOYEE NAME <br />C Jy •e/ h <br />-S OCIAL SECURITY NUMBER <br />COMPANY NAME . <br />JOBSITE NAME AN OR PO# <br />IC' ; C <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 />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 />t tJ`•' <br />� • �V <br />f <br />2 : <br />, <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 work related injuries wepo.rted to Selectemp <br />at the -time of injury. See reverse for further infarWton. - <br />X . <br />Signature of En p <br />CLIENT <br />We realize that to one of Selectemp's employees to our <br />payroll requires a settlement. See reverse for further information. I <br />hereby cert that the above hours are correct. <br />ture of Superviso. <br />TOTAL TOTAL - <br />Hours to nearest quarter.hour... ,3 /� <br />Title.. Date Ir <br />CUSTOMER COPY <br />