MALAYSIA

Medical Report For Foreign Worker

MC Ref. No : M085467 MEDICAL APPROVAL DATE : 06/01/2023 , VALID UNTIL : 06/04/2023

1. FULL NAME PHOTO

PUAD AGISNA SAPAUL

2. REGISTRATION NO IDN/182/C95/20230114122454/113317

3. FATHER'S NAME MASLAH

4. MALE / FEMALE MALE 5. AGE : 20 YEARS

6. PASSPORT NO C9507978

7. TYPE OF WORKER FOREIGN WORKER

8. RESIDENCE IN COUNTRY OF ORIGIN

ADDRESS
C9507978
MOYOT RT.000 RW.000 KEL.MOYOT KEC. SAKRA

KAB.LOMBOK TIMUR

COUNTRY INDONESIA

9. NAME OF RECRUITING AGENCY PT. TENAGA SEJAHTERA WIRASTA

10. ADDRESS OF RECRUITING AGENCY RUKO CAHAYA GARDEN BLOK F NO 11 RT003 RW006 KEL. SAD
AI KEC. BENGKONG - BATAM KEPULAUAN RIAU

I HAVE EXAMINED THE FOLLOWING DETAILS AND FOUND THAT :

1. HE IS FREE FROM THE FOLLOWING DISEASES/CONDITIONS :

YES NO YES NO
HIV/AIDS SYPHILIS
TB HEPATITIS B
MALARIA UNACCEPTABLE CLINICAL FINDINGS IN CHEST X-RAY
LEPROSY TUMOR/CANCER
FREE FROM OTHER CHRONIC DISEASES EPILEPSY

PHYSICAL EXAMINATION MENTAL ILLNESS

HEPATITIS C FILARIASIS

2. HIS URINE IS FOUND NOT TO CONTAIN OPIATE/CANNABIS/AMPHETAMINE

3. HE IS FIT TO WORK

4. I THEREFORE RECOMMEND THAT HE BE CONSIDERED FOR EMPLOYMENT

ADDITIONAL INFORMATION:

FIT TO WORK

DOCTOR SIGNATURE AND NAME DOCTOR ADDRESS

NUSA TENGGARA BARAT

DOCTOR SEAL

DR WIKAN TYASNING

DOCTOR QUALIFICATIONS
powered by
MBBS