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SE.LE(TEMP <br />EMPLOYMENT SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />01 CACC DQIAIT <br />EMPLOY E ' <br />�,A'i'�� <br />SOCIAL SECURITY NUMBER <br />CO ANY NAME _ <br />J BSITE NAME ND /O P6# <br />I w 0 �L� L mac,, <br />WEEK ENDING DATE <br />�v /�� <br />❑ ASSIGNMENT COMPLETED ICJ RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES . IF YES NOTIFY SELECTEMP IMMEDIATELY. <br />'B NO F <br />'Runday <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 />Z'3v <br />� L <br />2 :3o <br />'1 Z- <br />;7 3L) <br />FOR OFFICE USE ONLY <br />G. 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 timeof inju ee reverse for further information. <br />X . . <br />Signature of Empl�r <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 are correct._ . <br />X <br />Signature of, Supervisor <br />TOTAL TOTAL - --+� <br />Hours to nearest quarter hour. <br />I, I Title Date <br />CUSTOMER COPY <br />