Submit a Staffing or Private Duty Timeslip

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Daily or Weekly Pay:

Total Hours to
nearest 1/4 Hour:

I certify that the hours shown above represent my total hours worked

and that they were properly verified by the client or by an authorized representative. I certify I did not incur a work related injury while

working the above referenced shift(s).

I agree to terms of Net Upon Receipt and to pay interest on unpaid accounts over 30 days at the rate of 1 1/2% per month on unpaid balances (ANNUAL PERCENTAGE RATE OF 18%) or the maximum legal interest rate, whichever is lower, together with reasonable attorney's fees.

I recognize the rights of First Call as the employer and agree not to employ directly in any capacity the person named hereon without first providing First Call with at least ninety (90) days written notice following the termination of this assignment.

I certify that the hours shown above are correct and that the employee performed satisfactorily.

Thank you!