ANNEXURE - E

SIS CASH SERVICES (P) LTD

EMPLOYEE SEPARATION CLEARANCE FORM (ESCF)

(Only Part I – A and I – B to be filled by employee and returned to HRD)

This form is to be filled (in duplicate if the department requires a copy) on separation, for the settlement of final dues. In
order to obtain the full and final clearance on the relieving date, employees must submit complete this form and submit
to HRD latest by relieving date.

PART I
A. CLEARANCE FROM DEPARTMENT

Name:___________________________________________________Reg. No.:___________________________

Location: ___________________________________________ Department__________________________________

Job Band & Designation: ___________________________________________________________________________

Controlling officer________________________________________________________________________________

Date of joining:_____________ Date of Resignation:________________ Date of Relieving:___________________

Address for future correspondence:__________________________________________________________________

_______________________________________________________________________________________________

Personal Email ID: ________________________________________________________________________________

Contact No.: _____________________________________________________________________________________

I hereby declare that I do not have in my possession any property belonging to the SIS Group. I also agree to
complete any reference / appraisal for any of my repartees even after leaving the organization. I also hereby
authorize the company to provide any information as deemed fit, as a part of my reference check to any of my
prospective employers.

Signature of the employee: Date :

Important Documents/Manuals/ CDs/Floppies Yes/No/ Not Applicable

USBs, CDs, Hard Disk, Pen Drives, Data Card, etc Yes/No/ Not Applicable

Access Card, ID Card Yes/No/ Not Applicable

Keys (If any) Yes/No/ Not Applicable

Any Other:

Signature of Controlling Officer/person taking charge Date:

B. DETAILS OF ASSESTS (Employee to get sign offs from Dept. as the case may be)

(I) House
(a) Company Accommodation/leased/rented
(b) Charge taken by (name)
( c) Deposit amount
(d) Deposit recovery (Details)
(e) Payment to contractual staff
(f) Miscellaneous payment
(g) Recovery of company provided furnishing
(h) Recovery of assets (TVs, ACs, Washing machine etc)
(i) Any others (agreements etc)

Dept. signature & Date

(II) Vehicle (if older than 4 years and employees chooses not to buy it)
(a) Type of Vehicle / No.
(b) Original Documents & Keys
(c) Charge taken by (Name)
Dept Signature & Date

(III) Software / Hardware

(a) Cessation of Email, ERP Log In/SCO Log in
(b) Cessation of access of Information System / any other software
(c) Laptop / Desktop with accessories (PIs mention asset No. / Model)

IT Dept Signature & Date

(IV) Others
(a) Visiting Cards/ Calculator, etc
(b) Mobile Phone / Mobile Sim card/ Landline
(c) Corporate Credit Card
(d) Mediclaim Card
(e) Library Book
(f) Cubical drawer Keys
(g) Access / ID card
(h) Petro Card (if Any issued)
Dept Signature & Date

Any Others
 PART – II
CLEARANCE FROM HUMAN RESOURCES
(After verifying the above details, HRD will take approval and issue Office Order)

Kindly arrange to settle the dues based on the details given herein above. A copy of the settlement details may be
sent to me for information.

Employee Signature Date:

V. FOR HR USE ONLY ;

HR Comments:

Signature:
 ANNEXURE 1

TYPE RESPONSIBILITY FUNCTION CURRENT INDIVIDUAL Location

Reimbursement / Loan / Salary

Finance & Accounts Branch Accountant Branch Office
Advance

Email Id IT Sr. Manager IT Corporate Office

ERP Log In ERP Manager ERP Corporate Office

SCO Log in IT Sr. Manager IT Corporate Office

Laptop/ Mobile/ Data card IT Sr. Manager IT Corporate Office

Corporate Credit Card Finance & Accounts A. M. - Cash Flow Corporate Office

Mediclaim Card HRD Executive HRD Corporate Office

ID Card/ Access Card HRD Executive - HRD Corporate Office

__________________________________________________________________________________________________

Encl: Statement of Accounts – Payables/ dues against the resigning employee (Formatted in MS-excel)

__________________________________________________________________________________________________

Note:

* strike-off whichever is not applicable