Appendix 17

To: XQCC MANAGER,

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:
Appeal
3. 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 or0320954308Version No: AP Version 2.0

Appendix 6
COMMITMENT 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 signature
Name : __________________
NRIC : ___________________
Version No: AP Version 2.0