Employee Clearance Form
Employee Clearance Form
Employee Clearance Form
Type of Separation
Resignation ___ Termination ___ Lay Off ___ Retirement ___
Seasonal Lay Off ___ Leave of absence ___ Probationary ___ Department Transfer ___
Institutional Transfer ___ Other ___
Contact Information
Mailing address: Present Address:
ZIP Code: Contact No.:
Separation Date:
Employee Responsibilities
I have surrendered all [Check all that apply] which were entrusted to me during my employment
Company ID Badge ___ Cell Phone ___ Vehicle Gas Card ___ Vehicle ___
Technician Tools ___ Building Keys ___ Personal Computer ___ Maintenance Tools ___
Inventorial Property ___ Laptop/Notebook ___ Computer Equipment ___ Manuals ___
Vehicle Keys ___ Other ___ Other ___ Other ___
I have cleared all matters pertaining to petty cash funds and state expenditures. I understand that if I owe any outstanding
monies it may be withheld from my final paycheck.
I have been informed of the terms and conditions on my resignation.
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