www.pacificdr.

com

CLEARANCE FORM

Name: ______________________________ Designation: _________________________

Date Hired: ____________________ Effectivity of Resignation: _______________
Business Unit / Group: ___________________________
--------------------------------------------------------------------------------------------------------------------------------------

I. Employees Immediate Head: __________________________________

(Name and Signature)
Comments: _______________________________________________
_______________________________________________

II. IT Group
a. Laptop / Desktop: ___ Returned / Cleared

Remarks: _________________________________________________
IT Administrator (Name & Signature): ____________________________
Date Signed: ___________________________________

III. Admin Group

a. Phone and SIM Card (if applicable): ___ Returned / Cleared
b. Equipment/s assigned to employee: ___ Returned / Cleared

Remarks: _________________________________________________
Admin Officer (Name & Signature): ____________________________
Date Signed: ___________________________________

IV. HR Group
a. Company ID: ___ Returned / Cleared
b. HMO Card (if applicable): ___ Returned / Cleared
c. SSS Benefit Claim: (if there are documents to be signed or unclaimed benefits)
________________________________________________________
________________________________________________________

2/F Filipino Building., 135 Dela Rosa St., Legaspi Village Makati City, Philippines 1229
Phone: +63(2) 811-4593 | Fax: +63(2) 867-1560
 www.pacificdr.com

d. Remaining Leave Credits:

d.1 Vacation Leave: ______
d.2 Sick Leave: ______
d.3 Service Incentive Leave: ______

HR Officer (Name & Signature): ____________________________

Date Signed: ___________________________________

V. Finance Group
a. Company Loan: ___ Cleared
Remarks: _____________________________________________________________________
b. Excess Globe Billings
(if applicable): ____________________________
(Amount to be deducted from last pay, if any)

c. Amount of Cash Advance/s for Liquidation:

__________________________________
d. Remittances / Refund (if any): _______________________________
e. Tax Refund: ______________________________________________

Finance Officer (Name & Signature): ____________________________

Date Signed: ___________________________________

Noted by: Approved by:

Angelito Iya Maverick Evangelista

Vice President / CTO President / COO

HR-CLR-V001

2/F Filipino Building., 135 Dela Rosa St., Legaspi Village Makati City, Philippines 1229
Phone: +63(2) 811-4593 | Fax: +63(2) 867-1560