Client's Name: ___________________________________________ Address: ___________________________________________ Week Ending Date: Month _______ Day _______ Year ______ |
94 WALL STREET |
| DATE
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DAY |
TIME STARTED |
TIME FINISHED |
HOURS WORKED |
| SUN |
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| MON |
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| TUES |
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| WED |
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| THURS |
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| FRI |
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| SAT |
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TOTAL HOURS: |
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NURSE/CNA: I certify that the hours shown above represent my actual total hours worked for the week and the hours were verified by the client or authorized representative, and that no injuries sustained during this assignment.
NURSE/CNA: _________________________________________________
(Please print name and title, last name first)
NURSE/CNA SIGNATURE: _____________________________________
CLIENT: I certify that Quality Medical Staffing employee, named above, worked the total hours shown above and that this work was performed in a satisfactory manner. The client agrees to pay for the services immediatly upon receipt of an invoice for such services. and to pay interest on unpaid balance of any such invoice over 30 days old at the rate of 1 1/2% per month (annual percentage rate of 18%) together with reasonable attorney's fees for cost of collection.
CLIENT: __________________________________
(Please print name and title)
CLIENT: __________________________________
(Authorized Signature)