PT.

SRIWIJAYA BARA PRIHARUM

EMPLOYEE CLEARANCE FORM
INSTRUCTIONS:
1. Employee completes at least one week prior to separation, completes, signs, and obtains Department Head’s or Authorized
Person signature.
2. It is the employee’s responsibility to circulate the form to the departments listed below. In the event clearance cannot be
given by a department, the reason(s) should be given under “Notes”.
3. This Clearance Form must be completed and returned to the HRD Department before your last work day.

I. EMPLOYEE INFORMATION

Name : MUHAMMAD IQBAL Department : CHP

ID Number : 03-2003166 Work Location: TANJUNG LALANG
Job Title : FOREMAN QC Date of Separation: 31 DESEMBER 2020

II. GENERAL CLEARANCE

Department Date Returned Initial Note

Yes No
ID Card X
HRD X CAN’T BOOK
Company Regulation
Exit Interview 23/01/21 X

Cash Advance X
FINANCE
Personal Loan 27/11/20 X

Business Card X
ADM.
Keys 27/11/20 X

Vehicle X

Mobile Phone X
IT
SIM Card X

Computer X
SAFETY Safety Equipment 27/11/20 X

Kartu Akses Gedung APL X

OTHER

Employee signature : …Muhammad Iqbal Date : 23/01/2021

Dept. Head signature : …………………………. Date : ……/……/………

HRD Dept. Comments :