____________________________________
Name

Week of: _______________________________	Week of: _______________________________
Sunday         Date: _________ Hours: _________	Sunday         Date: _________ Hours: _________
Monday       Date: _________ Hours: _________	Monday       Date: _________ Hours: _________
Tuesday       Date: _________ Hours: _________	Tuesday       Date: _________ Hours: _________
Wednesday  Date: _________ Hours: _________	Wednesday  Date: _________ Hours: _________
Thursday      Date: _________ Hours: _________	Thursday      Date: _________ Hours: _________
Friday          Date: _________ Hours: _________	Friday          Date: _________ Hours: _________
Saturday      Date: _________ Hours: _________	Saturday      Date: _________ Hours: _________

Chancellor & Chancellor, Inc.	_____________________________________
Vendor	Total Hours
_____________________________________	_____________________________________
Supervisor Signature	Employee Signature

Please fax us by Monday 5:00p.m. after the close of the payroll period

{Note: If you are using MSIE, please use a medium font size to insure proper format}