Kino Tower Alam Sutera Lantai 8

Alam sutera, Jalan sutera Boulevard No. 1,

RT.002/RW.006 Panunggangan Tim., Kec.
Pinang, Kota Tangerang, Banten - 15143

Exit Declaration Form

Employee Name : Fika Afriliah ID : HQ0699

End of Emp Date : 31 Desember 2023 Department : TSP
Home Address : Jl. Kemandoran VIII No. 52, Grogol Utara
Kebayoran Lama, Jakarta Selatan
Telephone : Personal : Fikaafrillia30@gmail.com
081808974818
Number: Email

Type of Service Termination (Please tick one)

 Resignation  Retrenchment  Term Contract  Dismissal
Ended
 Other. Please
specify

Department (Please fill in with Employee’s Dept)

Receiver’s
N.A
Yes Signature, Name Remark
.
& Date
Job & documents handed over V
Pending Task V
Others : V
Supervisor/ Head of Department (Name, Sign, Date):

Finance Department
Receiver’s
N.A
Yes Signature, Name Remark
.
& Date
Travel Advance Repaid V
Loan Settlement V
Expense Settlement V
Others: V
Head of Finance Department (Signature, Name & Date):
 Kino Tower Alam Sutera Lantai 8
Alam sutera, Jalan sutera Boulevard No. 1,
RT.002/RW.006 Panunggangan Tim., Kec.
Pinang, Kota Tangerang, Banten - 15143

HR & Admin Department

Yes N.A Receiver’s Remark

. Signature, Name
& Date
ID Card Returned V
Laptop V
System Access Deactivated V
Door Access Deactivated V
Key V
Parking Card V
Others V
Head of HR Department (Signature, Name & Date):

I, Fika Afriliah , ID No. HQ0699 have not taken, extracted or copied any materials from the
files and documents of the Company for me or any third party’s possession and use. All files,
documents, etc which were held in my possession have been returned to the Company. I will
not at any time disclose to any third party any confidential information as to the business
dealings or affairs of the Company or as to any other matters concerning the Company, which
has come to my knowledge in the course of my employment.

Fika Afriliah, 01 Desember 2023

Acknowledged by Director (Signature &

Date) :

*Note: The completed form must be returned to HR Dept before the employee’s last payroll can be released.