Calvert Medical Associates
5304- #O Panola Industrial Blvd.
TIME SHEET Decatur GA 30035-4065
Phone: 1-800-322-7479-or-770-322-9131
Fax: 1-770-322-8698
Email: calvertmedical@bellsouth.net
Please complete time sheet accordingly
Contractor’s
DATE TIME LUNCH LUNCH TIME (contractor) TOTAL
IN OUT IN OUT SIGNATURE HOURS Name:
(Please Print)
1
2 Department:
3
Location:
4
Month: 200
5
6
Management Approval:
7 The undersigned hereby:
8 (1) Certifies that the hours noted are
correct and that the work was performed
9
in a satisfactory manner. And
10 (2) Confirms prior agreement between
Employer with respect to services
11 performed hereunder and any future
12 Services.
Approved by:
13 Department Supervisor Signature)
14 Date Signed:
15
Remarks: Time sheet must be signed and
16 approved before fees can be forward for
17 Locum Tenens services rendered.
18 Contact Information
19
Pager number:
20 ( ) -
21 Home number:
22 ( ) -
23
Fax number:
24 ( ) -
25
Work number:
26
27 Social Security /
28 Tax ID number: - -
29
30 Email:
31