STAFF SOURCE, LLC

2500 165th Street

Hammond, IN 46320

219.989.9675

219.989.3360 FAX

WORK VERIFICATION – Weekly Summary

Company Name:	Week Ending:

HOURS	WORKED
EMPLOYEE NAME	SUNDAY	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY	SATURDAY	TOTAL HOURS	OVER-TIME HOURS

HOLD HARMLESS AGREEMENT

Unless the client has obtained prior written consent of STAFF SOURCE, the client agrees not to ask or allow a staffing service employee to perform any of the following job related activities:

Driving an automobile or other motor vehicle;

Operating machinery other than office equipment; and

Handling cash, securities, or other valuables.

If this prior written consent is not obtained, the client agrees to waive all rights to make a claim against STAFF SOURCE, and to relieve STAFF SOURCE from all liability and responsibility for any damage, loss, or expense which the client incurs as a result of this staffing service employee engaging in such activities, and the client further agrees to indemnify and hold harmless STAFF SOURCE from and against all claims, damages, bodily injuries, losses, and expenses which might be caused as a result of the staffing service employee engaging in any of these activities.

Furthermore, the client agrees not to expose any STAFF SOURCE’s employees to unnecessary hazard, or extra hazard, and not violate any OSHA of safety law, rule, or regulation whether federal, state, or local. The client may be held liable as a result of their breach of this agreement.

The client recognizes STAFF SOURCE’s employer relationship with its personnel, and accepts the obligation to discuss all matters concerning their employment, job assignments, pay procedures, etc. with STAFF SOURCE.

By execution of this form, Client certifies that hours shown are correct; work was done satisfactory; that no one was injured on this job; and that Client agrees to the terms and conditions listed above.

See attached____________________________________	_________________

Authorized Signature	Date

Please fax weekly summary to STAFF SOURCE at 219.989.3360 on MONDAY MORNING