Date: DD / MM / YYYY

Client Name Designation

Company Name
Consultant Name PC Name
Consulting Contract Name
Consulting Kick-off Meet
Contract 1st Cheque Clear Date
Date

NO DUES/ CLEARANCE FORM

Employee Code: Employee Name:

Location : Department:

Date Of Joining: Date Of Resignation :

Last Working Date: Reporting Manager/ HOD’s Signature:

List of Documents/ Assets to be handover

OPERATIONS DEPARTMENT:

Documents/Assets (Please Signature’s: Ops.

Sl. No. Authorized Signatory Head
write the Articles name ) Surrendered/Deactivated

FINANCE

Sl. No. Documents/Assets Surrendered/ Authorized Signatory Signature’s :

Deactivated Finance Head

1 Travel Advance

2 Outstanding Loans / Advances

3 Reimbursements/Recovery (If Any)

INFORMATION TECHNOLOGY :

SL. No. Documents/Assets Surrendered Authorized Signatory Signature’s : IT

/Deactivated Head

1
 1 Desktop password Disabled

2 Laptop Returned

3 PEN /USB Drive/TAB/Pointer, Bag,

Charger, etc

LEARNING & DEVELOPMENT

Sl. No. Documents/Assets Surrendered/Submitted Authorized Signatory Signature’s: L&D

Head
1 Books Issued

2 Penalty (If Any)

3 Others

HUMAN RESOURCES

Sl. No. Documents/Assets Surrendered/ Authorized Signatory Signature’s :

Deactivated/Submitted Human Resource
Head

1 Resignation Letter- Accepted Copy

2 Task Handover Form & Exit

Interview
3 ID Card, Visiting Card, Drawer Key
or Any other (Please specify)

Note: All the Leaves are applied in HRIS, during the notice period: Yes No

Address for Communication (for all future correspondence i.e. Full & Final Cheques, Reliving letter etc.)

Contact Number ___________________________________________

Declaration
I hereby agree and acknowledge that all Intellectual Property (including but not limited to copyrights,
designs, trademarks, patents, logos) whatsoever in my possession during the course of my
employment with XXXXXX are exclusive property of the Company and I shall not, at any time, assert or
claim any right or interest thereto. I also agree that if proof of investment is not given at the time of final
settlement of dues, the entire income will be taken as taxable.

(Signature of the Employee) Date: ___________________