CLEARANCE FORM

Name and surname, title: …………………………………….
Unit: ………………………… Termination of employment as to the date: …………...
Library (Hollar, Jinonice, Opletalova)
Note: …………………………………….
Signature and date: …………….
Mr. Petr Balík, head of Operational and technical dpt., Smet. nábř. 6, Prague 1, across the yard, door
no. 1, line 213
Confirmation of Asset management
·  about submission of items on employee’s card + assets inventory as to the leaving date
Note: …………………………………….
Signature and date: …………….
·  about return of the keys of the workplace and used rooms
Note: …………………………………….
Signature and date: …………….
CIVT support, Smet.nábř. 6, Prague 1, 2nd floor, door no. 214, line 271
Confirmation of CIVT (IT office)
·  About submission of items and information of IT nature– fill in the CIVT appendix to the clearance form
Note: …………………………………….
Signature and date: …………….
Mrs. Martina Tóthová, Smetanovo nábř.6, Prague 1, 2nd floor, door no. 226, line 282
Confirmation of Economic department
·  about forfeiting the right of disposal towards accounting centres
Note: …………………………………….
Signature and date: …………….
Mrs. Jana Sahulová, Smetanovo nábř.6, Prague 1, 2nd floor, door no. 201a, line 283
Confirmation of Economic department
·  settlement of all advances
Note: …………………………………….
Signature and date: …………….
Mrs. Jitka Kendíková, Smetanovo nábř. 6, Prague 1, 2nd floor, door no. 204, line 233
Confirmation of Staff department
·  about return of Employee’s ID card
Note: …………………………………….
Signature and date: …………….
·  about return of Health insurance card (foreign nationals)
Note: …………………………………….
Signature and date: …………….
T-Mobile mobile services
Mrs. Klára Novosadová, Smetanovo nábř. 6, Prague 1, 2nd floor, door no. 206, line 236
Note: …………………………………….
Signature and date: …………….
Appendix to the Clearance form:
- Handover document of processed agenda
(i.e. signed by a leaving and accepting employee + a corresponding head).
- Assets inventory as to the leaving date
(i.e. a signed “Local List“, or a written record that the workplace has been completely handed over).
- CIVT appendix to the Clearance form
(i.e. a signed CIVT appendix that the workplace has been completely handed over in regards to data, email, software, hardware).
In Prague on: …………...
Signature of Employee:…………………………Signature of the Head ………………………………………

CIVT APPENDIX to Clearance form

(description of groups, mail, work data of an employee)

First name and surname, title: …………………………………….
Building and room number where you worked: …………………………………….
Description of activities (group, mail, setting of shares and their connection to the institute)
☐ Do you use a faculty mail? Describe: …………………………………….
☐ Do you use faculty mail forwarding (alias)? Describe: …………………………………….
☐ Do you use shares on S: disc? Which ones: …………………………………….
☐ Which offices did you use your work PC most? Describe: …………………………………….
☐ Are there any accounts, passwords to be handed over? Describe: …………………………….
☐ In case you administer faculty webs, insert their names as well as the names of persons who will
continue to administer them:
……………………………………………………………………………………………….…….
……………………………………………………………………………….…………………….
………………………………………………………………………………….………………….
……………………………………………………………………………….…………………….
…………………………………………………………………………….……………………….
Description of any other concrete information of IT nature which should be handed over to another
colleague at the same position (data storing for work on PC, specific problems with PC, MS Office,
other programmes, licenses, and so on):
……………………………………………………………………………….…………………….
…………………………………………………………………………….……………………….
……………………………………………………………………………….…………………….
………………………………………………………………………….………………………….
…………………………………………………………………………….……………………….
…………………………………………………………………………….……………………….
…………………………………………………………………………….……………………….
…………………………………………………………………………….……………………….
………………………………………………………………………….………………………….
In Prague on: …………... the Head (department, institute): …………………
On behalf of CIVT: ………………… Employee: …………………