CLEARENCE CERTIFICATE FOR THOSE GOING ON LEAVE /

LEAVING FOR GOOD (WORKERS)

Doc No : F 102 Rev No : 04 Date : 01.08.17

Name …………………………………………………….
Emp No …………………………………………………….
Trade / Designation …………………………………………………….
Division …………………………………………………….
Employment/Experience certificate: Required Not Required
Date of travel: / / Expected date of return: / / 15….

Received the following marked in good condition / damaged.

S. Please
Particulars Remarks
No Mark
1 QP Pass
2 Any other Gate Passes (Specify)
3 Sim Card, if any
4 Driving License
5 Tools / company belongings
Clearance from Traffic Dept
6
(Applicable for Drivers)
7 Mess Amount
8 Others
FOR OFFICE USE ONLY
Received the items as listed above / handed over to following person

Collected by : ……………………………
Signature : ……………………………
Recommendation for Employment /Experience Certificate - Workers Leaving for Good
Period of Employment …………………………………………………….
(Persons, who has not completed minimum 2 years contract will be given only Employment Certificate NOT Experience Certificate)
Performance
1 Attendance performance : Below average / Average / Good
2 Conduct : Any warning letters issued - YES / NO
3 If yes above, give details. :
4 Trade performance : Below average / Average / Good / Very Good / Excellent
Comments if any,
…………………………………………………………………………………………..
…………………………………………………………………………………………..

Signature Counter Signature

Head of Division (Manager: HR & Admin)

Important Note:
 The person going on leave must bring this form or else his settlement will not be cleared.
 This is the full responsibility of the person clearing the certificate for any loss of passes.