Student Clearance Form

COLLEGE NAME & CONTACTS

………………………………………………………………….

If there is an item not surrendered or debt not paid please mention it in the remark’s column. You can use additional plain paper signed by both parties to give the required details

ELIGIBILITY FOR CAUTION MONEY REFUND

The student is eligible/not eligible for the refund (Cancel inappropriate)

If not eligible please explain: ……………………………………………………………………………………………

……………………………………………………………………………………………Student Bank Account Information

Name…………………………………………………………………………………

Account Number………………………………Bank Name…………………………….

Student’s Signature……………………… Phone……………E-mail…………………

NOTE:

1. Original dully filled clearance form must be submitted to the administration office
2. A student must retain a copy of the dully filled clearance form for future reference
3. This form should be associated with the checklist of item to be cleared from by the student per each department.
4. An accountant should convert not cleared items to current market value price and be mention in the section of “For internal use only” below

***************** “For office use only” ********************

(Tick in the box at the right OR supply the necessary information)

Prepared by ………………………Designation ……………………Date …/../…

Approved by ………………………Designation ……………………Date …/../…

STUDENT CLEARANCE FORM

Mwisho (End):

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