From: ____________________Date: _________________1. Please find
attached X-Ray film (s) of Foreign Worker:1.1 Name:
_________________________________1.2 Worker Code:
_________________________________1.3 X-ray Film (s) dated:
_______________________________2. Reason for Despatch to
XQCC:Appeal3. Request for comparison & audit x-ray film and
reports:1st X-ray dated: _____________________________________2nd
X-ray dated: ____________________________________
NOTE:The filled-up form is to be attached to the X-ray film and
also faxed toPantai FOMEMA & Systems Sdn Bhd.Fax no:
03-20940969 or03-20954308Version No: AP Version 2.0
Appendix 6COMMITMENT LETTER
Date :To : Medical Division, Pantai FOMEMA & Systems Sdn
BhdEmployer Address :Tel No : (H) (O)(H/P) (Fax)Name of Foreign
Worker :Workers Code :Workers Passport no. :Country of Origin :I/we
____________________________, the employer of the above-mentioned
foreign worker,acknowledge that I/we am/are aware of his/her
medical
condition:_______________________________________________________________________
and duly undertake full responsibility for him / her. I/we declare
that in spite of the foreign workers medical condition described
above, I/we wishto employ/continue employing him/her as a
___________________________________ andhis/her duties are as
follows:1)_______________________________________________________________2)_______________________________________________________________3)_______________________________________________________________In
light of the medical condition described above I/we confirm and
assure Fomemathat I/wewill not assign him/her any tasks that would
aggravate the foreign workers medical conditiondescribed above and
put him/her/others health at risk. Additionally, I confirm that
I/we will bearany and all cost relating directly or indirectly
towards the medical managementof his/hermedical condition.I/we
confirm that Fomema shall not be held responsible in any manner
whatsoever,arising outof FOMEMAs certification of the above named
foreign worker as being suitable foremploymentin Malaysia despite
the medical condition described above. I/we further undertake to
holdFOMEMA harmless from any loss or liability arising from this
decision and agreeto indemnifyand keep FOMEMA from any loss or
liability arising from this decision.Authorized signatureName :
__________________NRIC : ___________________Version No: AP Version
2.0
