Clearence Exit Form
Name E-ID
Department/Position Last Date
Department Tick Check Item Department
Management
HR - GA 1. ID Card
2. Keys (Cabinet, Drawers)
3. Building Access Card
4. Name Card (Department)
5. Uniform
6. Rent car
7. Others
( ), Date
Finance 1. Clear Cash Advance
2. Expense Voucher
3. Company’s Loan
4. Personal Loan/ Others ( ), Date
IT 1. Hardware (Desktop / Laptop)
2. Email Account Cancellation
3. Printer
4. Hard-disk Drive
5. Modem
6. Smartphone / Tab
7. Software Manual / Books
8. Others
( ), Date
HR 1. BPJS Ketenagakerjaan Cancellation
2. Group Insurance Termination
3. Insurance Card Documents
4. COP / MOP / TOT
5. HRIS write off
6. Leave Balance Check
7. Employee Handbook ( ), Date
Clearance from Dept Head
No List Of Activities Status Remarks
(Pending/Completed)
Handing over done to (Name):
Employee Signature: Date:
Signature of person to whom handing over was done: Date:
Signature of Direct Manager: Date:
Since I signed this form on the date of my departure, I have no disputes or labor disputes with the
company and I have terminated my labor relationship with the company.
I promise to continue to perform the confidentiality terms after leaving the company and not directly or
indirectly disclose the company's trade secrets. The secret information refers to all the information that
you learned during your employment with the company or in any other way, including but not limited to
the customer. Lists, customers, technologies, inventions, know-how, business plans and strategies,
business models, customer information, website traffic information, finance, operational information,
program source code, employee training materials, graphic design works, and more.
If the company suffers losses due to non-compliance with confidentiality terms, the company has the
right to hold you accountable for the economic losses caused.
Employee Signature: Date:
