Sheet 1: New Clearance form

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	

		


		
	

		


		


		
Series of 2017
		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Local Government Unit
		
	

		


		


		


		


		


		


		


		
City of San Fernando, Pampanga
		


		


		


	
	

		
CLEARANCE FORM
		
	

		


		
	

		
I
		
PURPOSE
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		
Date of Application
		


	
	

		
TO:
		


		


		
City Government of San Fernando, Pampanga
		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		
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: __________________________________________________________
		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Office of Assignment: ____________________________
		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		
______________________________________
		
	

		
       Position/SG/Step: ____________________________
		


		


		


		


		


		


		


		


		
Name and Signature of Employee
		
	

		


		


		


		


		


		


		


		


		


		
	

		
II
		
CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		
We hereby certify that this applicant is cleared of  work-related accountabilities from this Unit/Office/Dept.
		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		
_______________________________
		


		


		


		


		


		
_______________________________
		


	
	

		


		


		


		
Immediate Supervisor
		


		
Head of Office
		


	
	

		
III
		
CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Name of Unit/Office/Department
		
Cleared
		
Not Cleared
		
Name of Clearing Officer/Official
		
Signature
		
	

		
1.
		
Administration Sector
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
a.
		
Supply and Property Procurement and Management Services
		


		


		
Engr. Michael N. Quizon
		


		
	

		


		
b.
		
Human Resource Welfare & Assistance
		


		


		
Ms. Rachelle S. Yusi
		


		


	
	

		


		
c.
		
Agency-accredited Union/Cooperative
		


		


		
Ms. Maria Teresa Q. Doble
		


		
	

		
2.
		
Library
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
a.
		
Legal Office Library
		


		


		


		


		


		
N/A
		
N/A
		
N/A
		
N/A
		
	

		


		
b.
		
Library Services 
		


		


		


		


		


		
N/A
		
N/A
		
N/A
		
N/A
		
	

		
3.
		
Finance and Assets Management
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
a.
		
Financial Services
		


		


		
Ms. Maria Gisel P. Rivera
		


		
	

		


		
b.
		
Transaction, Processing & Billing Services
		


		


		
Ms. Mary Ann P. Bautista
		


		
	

		


		
c.
		
Payroll & Remittance Services
		


		


		
Ms. Rachelle S. Yusi / Ms. Maria Gisel P. Rivera
		


		
/
		
	

		
4.
		
Professional and Institutional Development
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
a.
		
Scholarship Services
		


		


		
Ms. Rachelle S. Yusi
		


		
	

		
IV
		
CERTIFICATION OF NO PENDING ADMINISTRATIVE CASE:
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
a.
		
Internal Affairs Office/Legal Affairs Office
		


		


		
Atty. Atlee T. Viray
		


		
	

		


		


		


		

 
		
		
with pending administrative case
		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		
with ongoing investigation (no formal charge yet)
		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
V
		
C E R T I F I C A T I O N
		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


	
	

		


		


	
	

		


		


	
	

		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
EDWIN D. SANTIAGO
		
	

		
Signature over Printed Name of Agency Head