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EMPLOYMENT SIR.VI(ES <br />P.O. Box. 71250 • Eugene, OR 97401 <br />PI FAQ;: PRINT <br />EMPLOYEE NAME <br />2 5. Al 1 o n <br />S OCIAL SECURITY NUMBER <br />COMPANY NAME <br />In �+ <br />JOBSITE NAME ANDfOR PO# <br />r yC-_ . <br />WEEK ENDING DATE <br />D ASSIGNMENT COMPLETED Cl RETURNING NEXT WEEK <br />HAVE YOU HAD AN ON THE JOB INJURY THIS WEEK? <br />❑ YES. IF YES, NOTIFY SELECTEMP IMMEDIATELY. <br />❑ NO <br />Vn1.y <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 />DOZ3�. <br />FOR OFFICE USE ONLY <br />OURS' 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 b n authorized <br />representative: Also, any work related injuries were d to Selectemp <br />at the time of injury. See reverse for further informati <br />X <br />Signature of Emplo , <br />CLIENT' <br />We realize that to transfer one of Selectemp's employees to our <br />payroll requites a settlement. See reverse for further information. I <br />hereby ce ttfy that e- ebnV2'h rs are correct.. <br />x --, <br />Sign 6reof SupervVor <br />TOTAL TOTAL f7A <br />Hours to nearest quarter hour. (� <br />t! Title Date <br />9<<L • <br />CUSTOMER COPY . <br />