CLEARENCE FORM
1. Name of the employee :
2. Department :
3. Designation :
4. Date of Joining :
5. Period of service :
6. Reasons for leaving(Resignation OR Termination) :
7. Date of resignation: OR intimation of termination :
8. Date of acceptance :
9. Whether any amount to be recovered from the staff :
(excluding the items already informed to the admin department)
10. Mode of appointment
-Advertisement :
-Placement agencies :NIL
-Through employee reference:
-Direct:
11. Cost of recruitment
-Advertisement :
-Consultant fee : NIL
12. Whether the following items are returned
-Uniform
-Calculator
-Books
-Any other documents
-Keys of cupboards/Drawer
-Any other items which is used by the staff
Mobile
13. Whether any IOU is pending in the name of the employee?
14. Whether any staff advance is pending?
15. Whether any staff loan is pending?
16. Whether any other amounts are receivable?
17. Whether the employee is eligible for leave encashment? NA
18. Any training amount to be debited?
19. Whether any amount payable to employee yet to be determined?
(if yes, give details)
20. Recommendation of the Head of the Department?
(Specify the condition) RELIEVE
RELIEVE
SUBJEST
TO CONDITION
Recommendation of Manager Administration RELIEVE
RELIEVE SUBJESTTO
CONDITION
21. Signature of Director.
FINAL CLEARANCE FORM
DATE: ________________
Mr. ____________________________has left services of the Company with
effect from ______________.
You are requested to check outstanding in your department and give clearance
at the bottom of this memo.
_________________________
HR DEPARTMENT
Department OUTSTANDING (If Any) Name, Sign & Date
Head of the Department
HR Department
ID Card collected Yes / No
Loan/Advance
Amount Rs. ___________
outstanding
Others Yes/Not Applicable
Accounts Department Yes/No
IOU outstanding
Linen Department
(Uniform including shoes
if given)
Security Department
F & B Control Department
Stores Department
To be filled after above clearance is obtained
SERVICE CERTIFICATE TYPE : Satisfactory / Good / Others (Pls. mention)
Recommended by :
Head of Department
