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SELE(TEMP <br />EMPLO SERVICES <br />P.O. Box 71250 • Eugene, OR 97401 <br />PLFQSF PRINT <br />EMP 1 NAME <br />SOCIAL SECURITY NUK4BER <br />CTPANY NAME <br />a <br />JOBSITE NAME AND/Qh PO# <br />7 EEK ENDING DATE <br />I <br />❑ ASSIGNMENT COMPLETED D NEXT WEEK <br />f <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />.0"NO <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 />�� <br />I �2 <br />`Iz <br />� <br />IUUAL IUTAL <br />Hours to nearest quarter hour. r_ 3 <br />V, / <br />�i <br />EMPLOYEE COPY <br />FOR OFFICE USE ONLY <br />REG. 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 / juury y . See verse for further information. <br />X v r <br />Si g natu rerdi�EmMo'yee <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 certlfy,that the above hours are correct. <br />...Signa6re of Supervisor <br />Title Date <br />