CLEARANCE FORM

(To be completed before relieving letter is given)

NOTE :
1. Please do not keep any of the fields empty, as incomplete form will not be entertained.
2. Some of the fields may not be applicable to all, in such cases please mention N/A.
Name Employee ID

Date of Resignation Date of Relieving

Department Date of Joining

Designation Length of service

Tel No. Location

Email ID

Reason for Leaving

Name of immediate reporting manager
Designation of reporting manager

Address for Correspondence

S Name of the
Clearance Details Clearance By Signature
No Employee
Departmental Head
Departmental Head’s clearance for (Mention
1
relieving granted designation)
All official documents/CDs/Process
2
handed over
Personal Disk space cleared on
3
Computers
Date of clearance

Remarks:

Administration Department
Employee ID Card/Access Card
4
returned
5 Drawers cleared and keys returned
6 Mobile handset and Sim Cards returned
7 Data Card returned
8 Balance Visiting Cards returned
Telephone connection handed over (if
9
any)
Date of clearance
Remarks:

IT Department
Lap Top / Desktop and Accessories
10
returned
Authorization Code for STD/ISD
11
returned
12 Calling Cards returned
Date of clearance

Remarks:

Finance
13 Loans / Deposits cleared
14 Company credit card returned
15 Company forex card returned
16 Settlement of all dues done
Submission of all pending expense
17
vouchers done
Date of clearance

Remarks:

HR
18 Deactivation of access card
19 Exit interview conducted
Employee service agreement complied
20
with
21 Balance leave status cleared days;
22 Notice period to be recovered sorted days;
23 Deactivation from Official Mailing List
24 Deactivation from payroll system
25 Deactivation from HRIS/HRMS
Termination of record in software (if
26
any)
27 Deactivation of official email accounts
28 Employee directory updated
Date of clearance

Remarks:

Benefits
29 Accommodation facility discontinued
30 Parking permit handed over
31 Transport facilities discontinued
Medical insurance facilities
32
discontinued
Date of clearance
Remarks:

Stores
33 Equipment returned (if any)
Date of clearance

Remarks:

This is to certify that the above information is correct. The full and final settlement would be done
in

________________working days.

Approved by CEO : _________________________________ Date: _________________

Employee Signature: _______________________________ Date: _________________

________________________________________________________________________________
_______

For official use:

Clearance form received by HR department on:

Name :

Designation :

Signature :