Fillable Employee Clearance Form (Mississippi Delta Community College)

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Employee Clearance Form (Mississippi Delta Community College)

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The Employee Clearance Form (Mississippi Delta Community College) form is 2 pages long and contains:

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  • 30 other fields

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File type: PDF

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Employee Clearance Form
Employee Name
I D No.
Department
Will you continue PT?
Yes No
Last day to work
Do you plan to transfer leave to another state agency?
Yes No
If yes, what agency? ___________________________________________________________________________________________
Employee
Signature
Date
Please note: Clearance procedure is not complete without a copy of your resignation letter and Exit Interview Form.
Reason for Clearance:
Dismissal
Retirement
Leave of Absence
Other (Specify)
Before receiving your final pay, you are responsible to personally check with appropriate officials in the following functions or offices
and obtain their signature, indicating that you are cleared to leave and do not have any college property. Please contact the offices
below to check their operating hours.
Bookstore ___________________________________________ Facilities Management _______________________________
Information Technology ________________________________ Inventory __________________________________________
Student Services (Fines) ________________________________
Immediate Supervisor Certification
I certify that the above named employee has cleared all offices required; that he/she has no unauthorized college property; and all
necessary administrative actions have been taken to allow him/her to receive their last paycheck. I further certify that all keys within
the employee’s possession have been retrieved.
Signature
Date
Campus Dean/Division Lead/Vice President Certification
Signature
Date
Benefits Clerk/Payroll Clerk Certification
Amount of Leave Time Remaining _____________________
Signature
Date
District Human Resources Director Certification
I certify that all personnel actions required on the above named employee have been satisfactorily accomplished.
Signature
Date
Indianola Campus
Greenville Campus
Greenwood Campus
Moorhead Campus
Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual
orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs
and activities or in its employment practices. The following person has been designated to handle inquiries regarding the
nondiscrimination policies: Steven J. Jones, Vice President of Administrative Services, Tanner Hall, Suite 202, P. O. Box 668,
Moorhead, MS 38761, 662-246-6304; EEOC@msdelta.edu
EXIT Interview FORM
Name:
Employee ID #:
Job Title/Campus:
Employment Start Date: End Date:
Position:
Immediate Supervisor:
Why have you decided to leave Mississippi Delta Community College (MDCC)?
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your new job/company offer something that MDCC may need to consider? If so, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please share some things about your tenure at MDCC.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the things that MDCC does best from your perspective? What are the opportunities for improvement?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you feel that you had the support needed to perform well the responsibilities assigned to you?
__________________________________________________________________________________________
__________________________________________________________________________________________
What would you recommend for our consideration to help us create a better workplace?
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________ _________________
Employee Signature Date
The MDCC family hopes that you have a bright future and wishes you the very best.
Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual
orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs
and activities or in its employment practices. The following person has been designated to handle inquiries regarding the nondiscrimination
policies: Steven J. Jones, Vice President of Administrative Services, Tanner Hall, Suite 202, P. O. Box 668,
Moorhead, MS 38761, 662-246-6304; EEOC@msdelta.edu
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Employee Clearance Form (Mississippi Delta Community College)

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Completed 3 February 2021

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