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E L E(T E M P <br />E M P L O.Y M E-N T SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI FASF PRINT <br />IEMPLOY55 NAM <br />r. . <br />SOCIAL-SL/CU RITY N E <br />:, <br />, i y C0 NY E " <br />4P <br />ilOBSITE;NAME AND/ PO# " I <br />y Yr <br />E KZED DAT <br />❑ ASSIGNMENT COMPLETED ETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />Onday <br />Monday <br />Tuesday <br />Wednesday <br />Thursday <br />tf <br />a <br />Saturday <br />START <br />STOP <br />LESS <br />LUNCH <br />REG <br />HOURS <br />OVERTIME <br />HOURS <br />--- <br />�,OD).0 <br />V, <br />. Hours to nearest quarter hour. <br />, q< ir 6 <br />FOR OFFICE USE ONLY <br />6 S. 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 in . See rrrse for fuf information - - ,� <br />CUSTOMER COPY <br />