Medical Form Print v3
Medical Form Print v3
PENTING/IMPORTANT
Tempoh sah laku Borang Pemeriksaan Perubatan ini adalah 30 hari dari tarikh pendaftaran.
The validity of the Medical Examination Form is 30 days from the date of registration.
Berkuatkuasa pada 01 Januari 2020, sebarang permohonan untuk pembatalan dan tuntutan bayaran balik pendaftaran
pekerja asing hanya dibenarkan dalam tempoh sah laku Borang Pemeriksaan Perubatan.
Effective on 01st January 2020, any request for cancellation and refund for foreign worker's registration only will be
entertained within validity period of the Medical Examination Form.
Sebarang permohonan pembatalan pendaftaran/bayaran balik adalah tertakluk kepada yuran perkhidmatan sebanyak RM
25.0 bagi setiap pekerja asing.
Any request for cancellation of registration/refund will be subjected to service fees of RM 25.0 for each worker.
Sila pastikan semua maklumat di atas adalah tepat.
Please ensure that all information stated above is correct.
Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama passport asal untuk pemeriksaan perubatan.
Please bring along this Medical Examination Form together with the original passport for medical examination.
FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tersebut di atas.
FOMEMA will not responsible for any payment if the medical examination is carried out by medical facilities other than
named above.
No. Telefon : 0360398148 No. Telefon Majikan : 0360388997 Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp
ZINNA
Workers Name : SARABUTHEEN MOHEMED ALI
Workers Code : W6ES521650
Trans ID : 20230127994641
Nama Pekerja: SARABUTHEEN MOHEMED ALI ZINNA
Worker's Name
Kod Doktor: D2ES000160 No. Passport: U0536105
Doctor's Code Passport No.
Kod Makmal: L9ED000003 Kod Perkerja: W6ES521650 Jantina: MALE
Laboratory's Code Worker's Code Gender
Nama Makmal & DUNIA WELLNESS & Nama Klinik & KLINIK MEDISAFE
Alamat: LABORATORIES SDN BHD Alamat: 25A, LORONG ELMINA 2
Laboratory's 3-0, GROUND FLOOR Clinic Name & SG. BULOH COUNTRY RESORT
Name & Address JALAN SM 1 Address 47000 SUNGAI BULOH
TAMAN SUNWAY BATU CAVES SELANGOR
68100 BATU CAVES SELANGOR
No. Telefon: 0361851045 Sah Sehingga: 25/02/2023 No. Telefon Majikan: 0360388997
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp
ZINNA
Workers Name : SARABUTHEEN MOHEMED ALI
Workers Code : W6ES521650
Trans ID : 20230127994641
No. Telefon: 0360385113 Sah Sehingga: 25/02/2023 No. Telefon Majikan: 0360388997
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp