CLEARANCE FORM

To be filled in and returned to Human Resources for the Full & Final Settlement.
Name of the Employee: Employee Code:
Department: Location:
Date of Resignation:- Last working date:
Personal Email ID:- Mobile Number:-

I. Clearance from your Department

Please tick the appropriate boxes
Manuals / Books Company Documents Equipment  Samples Instruments Tools Brochures 
Mobile Phone (last statement to be attached) Files Pager Floppies / CD’s / Back up Tapes
Company Vehicle Any other  Sales Pocket Guide-It's mandatory for sales person
S.No. Description of handed over item * Returned To Sign
( Pls specify the name)

Important 1 : Kindly specify the date for removal of e-mail id from server

Important 2: Sales Pocket Guide – It's mandatory for the sales person to hand
over the same to the branch & branch coordinator should courier the same to
Head office.
Important 3 : Scaffoldless Tool – It's mandatory for the Area Manager & Assistant
Manager to hand over the same to the concerned person.

The employee has satisfactorily handed over his responsibilities. Signature of Department Head

II. Information Technology Equipment

Please tick the appropriate boxes
 Laptop Fax/Modem Card Lotus notes ID file Any other
S.No Description of item Sign

Signature of person responsible for

IT

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III. Clearance from Finance
Please tick the appropriate boxes
Advances Expense Reports Pending Bills Imprest Any other
S.No Description of item Sign

Signature of person responsible for Accounts

IV. Clearance from Human Resources

Please tick the appropriate boxes
Identity Card CLA Uniform Leave Card Any
other
S.No Description of item Sign

Note : If employee is availing of CLA, then a copy of the following needs to be attached
a. last paid telephone bill 
b. last paid electricity bill 
c. receipt showing settlement of cable expenses 
d. parking charges (if any) 
e. no dues certificate from society about society charges (if any) 
f. any other ___________________________________________________________________________

Remarks
Gratuity & PF dues will be paid by the RPFC, on receipt of application from the employee.
For HR use only
1. Information about LTA, Notice Pay, Leave Balance, Performance Bonus to be sent to SGC.
___________________
2. Information to be sent to Oriental Insurance.
___________________
3. Information to Citibank Suvidha .
___________________

Signature of HR Head