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2017
DOH-REGIONAL OFFICE V
Legazpi City
CLEARANCE FORM
(Instructions at the back)
I PURPOSE
Date of Application
TO: DOH-Regional Office V
I hereby apply for clearance from money, property and work-related accountabilities for:
Purpose: £ Transfer £ Resignation £ Other Mode of Separation:
£ Retirement £ Leave Please specify: __________________________
Effectivity/Inclusive Period: __________________________________________________________
_______________________________ _______________________________
Immediate Supervisor Head of Office
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Not
Name of Unit/Office/Department Cleared Cleared
Name of Clearing Officer/Official Signature
1. Administration Sector
ERLINDA M. CORNELIO
b. Human Resource Welfare & Assistance Supvg.Administrative Officer
c. Agency-accredited Cooperative
d. Agency-accredited Union
Philippines Public Health Association (Local
e. Chapter)
2. Library
LYNN E. ZULUETA
a. Legal Office Library/Library Services Librarian I
3. Finance and Assets Management
DANTE F. ATENTO
a. Financial Services Administrative Officer V
RESTY D. DAEP
b. Transaction, Processing & Billing Services Accountant III
V. C E R T I F I C A T I O N
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INSTRUCTIONS:
2. This clearance should be duly accomplished before paying the last salary or
any money due the employees. (Specify which type of clearance: maternity
leave, retirement, transfer, etc.)
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