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., <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PI PASF PRINT <br />EMPLOYEE NAME <br />-a VA LA cl�- CGr`e� <br />SO IAL SECURITY NUMBER <br />CO MPANY NAME <br />E \-k - v \-PZ <br />JOBSITE NAME AND /6R PO# <br />WEEK ENDING DATE <br />❑ <br />AS 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 />• <br />Sunday <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 />l <br />Lo .5 <br />Z . 30 <br />Hours to nearest quarter hour. . <br />CUSTOMER 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 Selecternp <br />at the time of injury. See reverse for further information. <br />X LL VNIv 4i <br />Signature of Employee U . <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 certify. that the above hours a r <br />X <br />.Signature of Supervisor <br />G <br />is <br />title Date <br />