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Name of Employee ____________________________________________ Date Hired _________________ Date of Separation______________________

Employee Number _______________ Position______________________ Last Working Date___________
Division/Store Assignment ______________________________________ Address _________________________________________________________
Email Address ________________________________________________ _________________________________________________________
Contact Phone # __________________________________________________

In connection with my separation from the Company, I would like to request for one (1) set of documents*:
_______Option 1: Please send the documents via courier services to the above mailing address.
 Please deduct P100.00 from my quitclaim payment representing postal charge and services.
 Please see attached receipt for P100.00, which I paid to Treasury, representing postal charge and services.

_______Option 2: I will pick up the documents on (please indicate exact date) __________________________

_______I have no need for the documents at this time.

Option 2: Please claim documents from JWS Salary Admin. Please note that if documents are unclaimed on the indicated date, owner must once again
request for their preparation.
Option 2: Please bring valid ID upon claiming. If through a representative, present authorization letter and photopy of IDs of employee and representative.
* One Set includes: (1) Payslip, (1) Copy of Clearance Form, (1) BIR Form 2316, (1) Certificate of Employment, SSS, Philhealth, and Pag-Ibig Fund Contributions

Would you like more than one copy of the Certificate of Emplotment? (Please check.)
_______ Yes. Indicate total no. to be requested (max of 5)_____
_______ No, thanks.

Signature of Employee/Date Signed

Note: Please print the form, fill out necessary information, and submit to JWS Salary Admin.