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SELE(T <br />xJMPL0TMEN "T SERVI("E5 <br />P.O. Box 71256 • Eugene, 019.97401 <br />DI FACE -DOINT " <br />EMPLOYEE NAME <br />car el� <br />SOCIAL SECURITY NUMBER <br />COMPANY NAME <br />JOBSITE NAME AND /OR PO# <br />;C <br />WEEK ENDING DATE <br />[] ASSIGNMENT COMPLETED : ' QRETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURYTHIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />tip <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 />�'z <br />Z :3 <br />FOR OFFICE USE ONLY <br />HOURS, I 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 th Bent or ort by an aut m horized <br />representative. Also, any work related injurie ere reped to Selectep <br />at the time of injury. See reverse for further ormation. - <br />x <br />Signature of Employ <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 />Signature of Supervisor} ^� <br />TOTAL TOTAL . L/i/ <br />Hours to nearest quarter hour: <br />Title bate <br />CUSTOMER COPY <br />