Form No: 09/01/04

Separation Clearance Form

Date: --------------------------

A. Employee Details

Employee Name
Department Unit / Section
Position Grade
Date of Joining Date of Birth
Year of Services Age
Last Working Day

B. Reasons for Separation:

SN Reasons √
1 Resignation
2 Termination – Medical
3 Termination – Discipline
4 Termination – Other
5 Permanent Disability
6 Death
7 Other (Please specify)

C. Employee own Department NCC:

This is to confirm that the above staff has handed over all the files, documents, materials
and all other Department’s belongings which were in his/her custody and the Department
has no further claims.
HOD Comments

_______________________________________________________________________

HOD Signature ------------------------------ Date: ----------------------

Form No: 09/01/04

Separation Clearance Form

D. Finance Department NCC:

This is to confirm that the above staff has paid all his loans (if any) and other financial
claims and has no further liabilities toward the Company
HOD Comments

_______________________________________________________________________

Finance Manager Signature ------------------------------ Date: ----------------------

E. Administration Department NCC:

This is to confirm that the above staff has returned the Company’s flat / Company’s
furniture (if any) and paid all the utility and Telephone bills and has returned all
Company’s belongings that were in his/her custody
HOD Comments

_______________________________________________________________________

Finance Manager Signature ------------------------------ Date: ----------------------

F. Payroll Section – HR Department NCC:

This is to confirm that the above staff has paid his personal loan (if any) and other dues
and have no liabilities toward the Company
Payroll Section Comments

_______________________________________________________________________

Payroll – In-Charge Signature ------------------------------ Date: ----------------------

Form No: 09/01/04

Separation Clearance Form

CEO’s Comments

_______________________________________________________________________

Signature ------------------------------ Date: ----------------------

HR Actions / Comments

HR - Manager: -------------------------------------- Date:---------------------

Copy for Employee Personal File

Copy for Finance Department