STAFF CLEARANCE FORM

STAFF NAME: STAFF NO STATION

Will terminate my services effective (DD/MM/YYYY) SIGNATURE

FORWARDING ADDRESS

P. O. Box Postal Code Town ____

Tel/Mobile _____
E-mail______________________________________

FOR HR RECORDS OFFICIAL USE ONLY (To be signed after all signatories have completed and signed the form)
I have checked that the details provided in the form are complete and have been verified by me against
originals where applicable:

Name of HR Officer: Signature: Date:

I confirm that the above-mentioned member of staff has cleared all requirements and (where
applicable) has correctly handed over to his/her relief. The following amounts are recoverable
or payable to the staff:
Recovery
Amount Reason for recovery Signature Date
CONTROLLING MANAGER
DEPT DIRECTOR/AREA
MANAGER
HUMAN RESOURCE MANAGER
- Bank Informed of exit?
MEDICAL CLINIC/WELFARE

WANANDEGE SACCO

CORPORATE LIBRARIAN
COMMERCIAL STORES
MANAGER
PROPERTIES & FACILITIES
MANAGER
TECHNICAL LIBRARIAN

IS OPERATIONS MANAGER
IS COMMUNICATIONS
MANAGER
MOTOR TRANSPORT
MANAGER
ACHL SACCO
SECURITY SERVICES
MANAGER
CREDIT CONTROL MANAGER
PAYROLL SERVICES
MANAGER
The below are payable to Amount Reason for payment Signature Date
the staff payable
HR REGISTRY LEAVE
BALANCE
HR REGISTRY OVERTIME @
1.5
 HR REGISTRY OVERTIME @
2.0
Distribute Copies as follows: 1.Original-HR Records 2. Copy Payroll 3. Copy-Provident Fund
office 4. Staff Copy
Revised 01Jul 2015