WORK WITH US HUMAN RESOURCE SOLUTIONS INC

Employee Clearance Form

This form is used to certify that all office property and other dues have been returned and rights to access property or services have
been appropriately discontinued. Managers must clear employee of all departmental obligations

Employee Information

Name of the employee

________________________________________________ Employment No. _________________

Department
________________________________________________ Date Of Separation _________________

Forwarding Address
__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________
Telephone No.

Type of Separation

Resignation

Retirement

Transfer To
_______________________________________________

Department Clearance
Your final pay will not be given to you unless you have cleared the following Company/Department/Branch/Person as to cash
and property accountability with the Company.

Items Received / Amount Name & Signature Date Remarks

Payable
ADMINISTRATION (WWU)

PROPERTY

Personnel Benefits
SSS Maternity/sickness
Insurance Overpayment
SIL Balance
PAYROLL/TIMEKEEPING
Last day of Attendance
Payroll Adjustment
WWU ADMIN
Vehicle - FLEET CARD
Identification Card / Access Card
Cellular phone
Uniform
Any Other ( Please Specify )
I understood that I, the subject person and the company, its signatories and department head are head are relieved of any
responsibility from the date of this clearance.
I hereby pronounce that I no claims whatsoever against the company arising out or in connection with my employment.

Employee's Signature Department Head's Signature HR Signature Payroll

Date Date Date Date