CLEARANCE & NO DUES FORM

Name: Reason for Leaving:

Designation: Notice given on:

Employee Separation effective

Code: close of work on:

Department: Details of Service

Project Agreement (if any)

Date of Joining: Notice period:

Date of Birth: Declaration signed

(Yes/No)

ESOP Entitlement
(Yes/No)
[A] EMPLOYEES THEMSELVES MUST GET CLEARANCE FROM EACH DEPT.
BEFORE HANDING IT TO HR DEPT.
WHETHER ANY THING IS DUE FROM EMPLOYEE IN SIGNATURE

1 Self Deptt………………………………………… ………. …………………………….

2 Stores…………………………………………………… …………………………….

3 Health Card …………………………….. …………………………….

4 Drawing Office (For technical persons) ……………………………..

5 Mess………………………………………………………. ……………………………..

6 Administration………………………………………… ……………………………..

7 Officer Club…………………………………… …………………………….

8 IT………………………………………………………….. …………………………….

9 HR -------- (Mobile, Identity Card, Sim) …………………………….

TO HR SPOC ON…………………………………………. Sign (HR)………………….

[B] HR PAYROLL: PLEASE FURNISH THE DATA RELEVANT FOR FULL AND FINAL
SETTLEMENT
1 Days payable [Month-Year]……………… = ............................................................ days

2 No. of days of leave payable…………….. = ........................................................... days

3 Notice pay to be deducted……………….. = Rs ................................... only

4 Bonus / Ex-gratia payable……………….. = Rs ................................... only

5 Any other relevant information. ……………………………………………………………

SIGNATURES: PAYROLL. In-charge……….……. HEAD (HR)………………………

DATE: DATE:
Comments of Head – HR

HR to Accounts on…………………………. Signature (Head - HR)……………………...

[C] ACCOUNTS:
AMOUNT TO BE ADJUSTED AGAINST:

1 Advance taken Rs .................................................... only

2 Loan taken Rs .................................................... only

3 Rent Rs .................................................... only

4 Value of item Rs .................................................... only

5 Any other…………………………………………………………………………………..

………………………………………………………………………………………………
SIGNATURES

Dealing Asst [I] Salary & Wages………………….. Dept. Head……………………

Officer: [ii] Other Expenses…………………
[D] CASH OFFICE: PLEASE PAY DUES AFTER MAKING ADJUSTMENT AS
MENTIONED IN [C] ABOVE

Signature Cash Office Asst/Officer Date: