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COLLEGE NAME & CONTACTS

………………………………………………………………….

Year/Level On Campus Off Campus
Student Details Clearance Reasons
Name of the Student…………………………………………… Transfer  
Registration Number………………………………………….. Completion  
Course of Study: ……………………………………………….. Withdrawal  
SN DEPARTMENT

(See the relevant checklist of items to be cleared attached)

CLEARING OFFICER SIGNATURE DATE REMARKS
1  

…………………..

 

 

2  

…………………..

3  

…………………..

4  

…………………..

5  

…………………..

6  

…………………..

7 HOD (Academics)

 

8 Practical and IPT Coordinator

 

9 Library

 

 

 

10 Warden’s Office

 

 

 

11 ESISSO

 

 

 

12 HOD (Finance & Administration)

 

13 Principal’s Office

 

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)

 

This student is cleared from all institute items/ debts.

 

 

 

 

This student is not cleared from all institute items/debts.

Items damaged or dept own value to TZS. …………………………

 

 

 

 

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

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

STUDENT CLEARANCE FORM

Mwisho (End):

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