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- SELE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLEASE PRINT <br />I EMPLOYEE NA E till I/ <br />SOCIAL SECURITY NUMBER <br />C PANY NAME <br />C, �, , <br />JOBSITE NAME AqD/0R PO# <br />G- o c , lt <br />IV WEEK ENDING DATE <br />I <br />❑ ASSIGNMENT COMPLETED TURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YE IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />NO <br />nday <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 />0 <br />( 2. <br />6 <br />2, 3o <br />'I z <br />Z °30 <br />'1z <br />TOTAL TOTAL <br />TOTAL <br />V <br />Hours to nearest quarter hour. <br />op <br />SELECTEMP COPY <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 injury. See reverse for further information. <br />X <br />Signature of Employ <br />CLIENT <br />We realize that to transfer one of Selectemp's employees to our <br />p <br />wires i s settlement. See reverse for further information. I <br />cer i at the abov ( ereby <br />Signat of Supervis <br />Title Date <br />