To: ehs@fiu.edu, propertycontrol@fiu.edu,tcert@fiu.edu, stan@fiu.edu, hr@fiu.edu, keycontrol@fiu.edu,expatron@fiu.edu
Subject: Separation Clearance Form For [emp_name]                  
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FLORIDA INTERNATIONAL UNIVERSITY     
DIVISION OF HUMAN RESOURCES          
SEPARATION CLEARANCE FORM         
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Name of Staff/Faculty:
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Name:  [emp_name] 
Panther ID#:  [pan_id]
Dept:  [dep_name]
Separation Date: [sep_date]
Job Title:  [job_title]
Retiree:  [ret]

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Checklist:
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Access to computer systems:  [box_1]
Beeper: [box_2]
Cash advances: [box_3]
Cellular telephone: [box_4]
Charges for personal phone calls: [box_5]
Child care fees: [box_6]
Credit cards: other - [box_7]
Hardship loans/guarantees: [box_8]
Lab equipment/supplies: [box_9]
Lab keys/Access cards: [box_10]
Library books/materials: [box_11]
Named removed from authorized signature list(s): [box_12]
Office keys/Access cards: [box_13]
Passwords, IDs, etc. terminated: [box_14]
PC's - Laptops/PDA Devices: [box_15]
Safety apparel or equipment: [box_16]
Salary overpayments: [box_17]
State of Florida Purchasing Card: [box_18]
Telephone and effort certification: [box_19]
Time and effort certification: [box_20]
Tools: [box_21]
Traffic fines: [box_22]
Travel advances: [box_23]
Uniforms: [box_24]
University ID card: [box_25]
University property: other - [box_26]
Licenses, permits, hazardous and all specialized, regulated or controlled materials have been properly disposed: [box_27]

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Department Head/Supervisor Certifications
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Supervisor Name:  [print_name]
Supervisor's Phone Number:  [sup_phone]
Date Submitted:  [sup_date]

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Clearance approval withheld for the following reason(s):
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[clear_reason]