THE PAKUBUWONO MENTENG

CLEARENCE FORM
To be completed by Human Resources Division.
Name : Position :
Employee No : Dept/Div :

Commencement Date : Last Working Date:

Last Payment Date:
Reason for Leaving
Resignation Dismissal Lay Off

The following materials must be returned to the Human Resources Division.

Name Tag ID Card Locker Key Associate Hand Book

Uniform Shoes Access Card Insurance Card

HT/HP Car key Parking Tag Business Card Hand Over

To be completed by Human Resources & Finance

Amount due to employee Amount due to hotel Balance

Basic Salary Rp. Training Fee Rp. - -
Outstanding AL (3 days) Rp. Unpaid Leave Rp. - -
Meals & Transportation
Rp. - Others Rp. -
Allowance
Overtime Allowance Rp. - BPJS TK (JHT) Rp. -
Severance Pay Rp. - BPJS TK (JP) Rp. -
Others Rp. - BPJS Kesehatan Rp. -
Total Rp. - Total Rp. - -

Employee/Date I hereby stated that :

1. The company does not owe me anything as of to date,
2. Will not enter the hotel premises for the period of next 6 (six) months
due to my resignation or 1 (one) year due to the termination.

ACKNOWLEDGED BY,
HRM/Date

JAM/HR-11/05