CS Form No.

7
Series
Seriesofof2017
2017
Local Government Unit
City of San Fernando, Pampanga
CLEARANCE FORM

I PURPOSE

Date of Application
TO: City Government of San Fernando, Pampanga
I hereby apply for clearance from money, property and work-related accountabilities for:
Purpose: £ Transfer £ Resignation £ Other Mode of Separation:
£ Retirement £ Leave Please specify: __________________________
Effectivity/Inclusive Period: __________________________________________________________

Office of Assignment: ____________________________

______________________________________
Position/SG/Step: ____________________________ Name and Signature of Employee
II CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES
We hereby certify that this applicant is cleared of work-related accountabilities from this Unit/Office/Dept.

_______________________________ _______________________________
Immediate Supervisor Head of Office
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Not
Name of Unit/Office/Department Cleared Cleared
Name of Clearing Officer/Official Signature
1. Administration Sector

Supply and Property Procurement and Engr. Michael N. Quizon

a. Management Services

Ms. Rachelle S. Yusi

b. Human Resource Welfare & Assistance

Ms. Maria Teresa Q. Doble

c. Agency-accredited Union/Cooperative
2. Library

N/A N/A N/A N/A

a. Legal Office Library

N/A N/A N/A N/A

b. Library Services
3. Finance and Assets Management

Ms. Maria Gisel P. Rivera

a. Financial Services

Ms. Mary Ann P. Bautista

b. Transaction, Processing & Billing Services

Ms. Rachelle S. Yusi / Ms. Maria Gisel P. Rivera /

c. Payroll & Remittance Services
4. Professional and Institutional Development

Ms. Rachelle S. Yusi

a. Scholarship Services
IV CERTIFICATION OF NO PENDING ADMINISTRATIVE CASE:

Atty. Atlee T. Viray

a. Internal Affairs Office/Legal Affairs Office
with pending administrative case
with ongoing investigation (no formal charge yet)

V CERTIFICATION

EDWIN D. SANTIAGO
Signature over Printed Name of Agency Head
 CS Form No. 7
Series of 2017
Series of 2017 SAMPLE
Local Government Unit
City of San Fernando, Pampanga
CLEARANCE FORM

I PURPOSE

November 20, 2017

Date of Application
TO: City Government of San Fernando, Pampanga
I hereby apply for clearance from money, property and work-related accountabilities for:
Purpose: £ Transfer £ Resignation £ Other Mode of Separation:
£ Retirement £ Leave Please specify: __________________________
Effectivity/Inclusive Per Travel Abroad /December 18-22, 2017

Office of Assignment: City Human Resource Development Office

Carolyn H. Rosales
Position/SG/Step: Administrative Assistant II /8/5 Name and Signature of Employee
II CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES
We hereby certify that this applicant is cleared of work-related accountabilities from this Unit/Office/Dept.

Hazel S. Mallari Rachelle S. Yusi

Immediate Supervisor Head of Office
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Not
Name of Unit/Office/Department Cleared Cleared
Name of Clearing Officer/Official Signature
1. Administration Sector

Supply and Property Procurement and Engr. Michael N. Quizon

a. Management Services

Ms. Rachelle S. Yusi

b. Human Resource Welfare & Assistance

Ms. Maria Teresa Q. Doble

c. Agency-accredited Union/Cooperative
2. Library

N/A N/A N/A N/A

a. Legal Office Library

N/A N/A N/A N/A

b. Library Services
3. Finance and Assets Management

Ms. Maria Gisel P. Rivera

a. Financial Services

Ms. Mary Ann P. Bautista

b. Transaction, Processing & Billing Services

Ms. Rachelle S. Yusi / Ms. Maria Gisel P. Rivera /

c. Payroll & Remittance Services
4. Professional and Institutional Development

Ms. Rachelle S. Yusi

a. Scholarship Services
IV CERTIFICATION OF NO PENDING ADMINISTRATIVE CASE:

Atty. Atlee T. Viray

a. Internal Affairs Office/Legal Affairs Office
with pending administrative case
with ongoing investigation (no formal charge yet)

V CERTIFICATION

EDWIN D. SANTIAGO
Signature over Printed Name of Agency Head