CLEARANCE CERTIFICATE

Employee name: Employee Location:

Code:
Designation: Level: Dept./Sub Dept:
Date of joining: Last day of work:
Date of resignation :
Contact Address: Landline Tel No:
Mobile No:
Email address:
Any Home
Loan Yes NO
From SBI
Employee
Any
Confirmation YES NO
Personal Yes NO
Loan
From SBI

OWN DEPARTMENT [Please indicate status as Yes/ N.A (not applicable) or fill in details.
Please do not keep any response blank]
Handover to Passwor Key Travel PACER
authorized ds s expenses/ Assessment of
person bills claimed employees
supervised
Documents/ Files/Calculator/ Any other Comments, if any:
Company Asset
Name: Signature:
Date:
ACCOUNTS
Outstanding Loans/ Advances: Outstanding bills/ clearing of
bills:
Total amount to be adjusted: Rs. Remarks:
Name: Signature:
Date:

IT
Lapto Any other LAN ID/ Lotus Computer Remarks:
p item Notes Storage
(specify) ID deleted on Devices
Name: Signature:
Date:
ADMINISTRATION
Mobile ID - Visiting Company
Phone Card Cards Books
Leave Status: PL: SL: CL: Remarks:
Name: Signature:
Date:
HUMAN RESOURCE
Notice Notice Pay paid Date
Period Amount Rs. vide d
PACER PF to be / Exit Interview
Assessment of Transferred Withdrawn done,
employees recorded &
supervised attached
Comments:
Name: Signature:
Date:
FULL AND FINAL SETTLEMENT
(To be filled by HR)

R/HRFormat/ClearanceFormat/PW 1/9/05
 PAYABLE AMOUNT Amount (Rs)
1. Salary to be paid from………… to …………
2. Medical Reimbursement (if due) against bills
3. L.T.A (If due) against application form duly signed by the authorized
signatory
4. Telephone Reimbursements (if any) against bills
5. Gratuity (if applicable)
6. Any other payment (please specify)

RECOVERABLE AMOUNT
1. Advances (if any)
2. Tour Advances
3. Any other deduction (please specify)
NET PAYABLE NET RECOVERABLE
Rs. Rs.
PF Amount to be Transferred/ Withdrawn
Name: Signature:
Date:

R/HRFormat/ClearanceFormat/PW 1/9/05