EMPLOYMENT CLEARANCE FORM

Employee Information
Name: ROHITH PANDICHERRY
Emp. Code: ______3429________________
Designation: __RENTAL SALES AGENT ______________ Department: ____D20 - DEPARTURE_____
Reporting Mngr.: __K.P.Suresh_____________________ Location: ________D18_________________
Joining date: ___29-03-2011________________________ Last working date: __23-11-2012________
Remarks:___Resigned_____________________________
Mobile No.:___055-6470564 __________

Resigned & terminated employees are required to surrender all company property given for fulfillment of
job. All of these shall be returned to respective Departments before the last working date & authorize
signature shall be affix in this form as acknowledgement of complete return. This shall contain also
necessary deductions need to be made against the employee, justification should be attached.

Please check appropriate boxes, kindly specify other items surrendered or necessary
description.
1. Employees Department: ____________________________
a) Related files- password/ soft copies __________N/A________________
b) Telephone & supplies e.g. stapler, scissors, stationeries, etc. _________N/A____________
c) Company car/ car keys with VDR ___N/A________

e) Petrol Card ______N/A____________

d) Cabin/ office/ drawer/ file keys_____N/A________

f) Cheque books _______N/A_______

g) Other things as applicable___________N/A__________________

Outstanding item: _______NIL________________
___________________________

Amount to charge:

Cleared by: __NASIRUDEEN

2012____________

_________(Name & Signature) Date: ____27-11-

2. IT Department
a) PC set/ laptop ______________________
b) E-mail ID

______________________

c) Personal printers, fax machine_______________

d) CDs, DVD, USB etc._________________________

Outstanding item: _______________________

Amount to charge:
___________________________
Cleared by: _____________________________(Name & Signature) Date: ___________________________

3. Accounts Department
a) Salary Advance______________________________

b) Petty Cash_______________________________

c) Traffic Fine __________________________________

d) Telephone charges_______________________

e) Personal Company Loan (if given)_____________

f) Vehicle Hiring charges ___________________

Outstanding item: _______________________

Amount to charge:
_________________________
Cleared by: _____________________________ (Name & Signature) Date: __________________________

4. Human Resources Department

a) Company ID _________________________________

b) Labour Card & Insurance Card (for visa cancellation) __________________________________

c) Family Insurance Card (if issued) _____________
d) GSM Chip or/ and mobile phone_____________
e) Uniform deduction __________________________
f)

Recruitment cost

__________________________

g) Library books/ materials______________________

h) Bank Loan details ___________________________

Account No._________________________

Outstanding item: _______________________________

Amount to charge: _________________
Cleared by: _____________________________________(Name & Signature) Date: _______________

Remarks:
__________________________________________________________________________________________
Note:

This document will be attached in the request of HRD for your FINAL SETTLEMENT; any dues will be charge to your
final pay.
Incase the space provided above is not sufficient to list other items; an additional separate paper can be
attached.

QR/HR/ECF/009: Issue Status:01