UNITAB MEDIC SDN. BHD. (312291-X) A-18-1, Level 18, Hampshi re Place Offi ce, 157 Hampshir e, 1 Jalan Mayang Sari, 50450 Kuala Lu mpur . Tel: 03-2782 8777 Fax: 03-2782 8778 www.fomema.com.my BORANG PENDAFTARAN PEMERIKSAAN PERUBATAN PEKERJA ASING FOREIGN WORKER’S MEDICAL EXA MINATION REGISTR ATION FORM BAYARAN PENDAFTARAN / PAYMENT FOR REGISTRATION RM 190 (perempuan) atau RM 180 (lelaki) dalam bentuk Draf Bank, Kirima n Wang, Wang Pos, CIMB Clicks atau Kredit Kad melalui POS Online atas nama FOMEMA SDN. BHD. RM 190 (female) or RM 180 (male) in the form of Bank Draft, Money or Postal Order, CIMB Clicks or Credit Card through POS Online payable to FOMEMA SDN. BHD. Bayaran pendaftaran TIDAK AKAN DIKEMBALIKAN.Payment for registration is NON REFUNDABLE. Pemeriksaan kesihatan mesti dijalankan dala m tempoh 90 ha ri dari tarikh pe ndaftaran. The Medical Examination must be done within 90 days from the date of registration. JENIS PENDAFTARAN / TYPE OF REGISTRATION(TANDAKAN “ √” / TICK “ √” ) Sila bawa dokumen-dokumen berikut / Please bring the following documents: Pendaftaran kali pertama (Ketibaan baru) / First tim e registration (New arrival) 1. Dokumen asal / Original document i. Paspot asal / Original passport 2. Dokumen salinan / Photocopy documents i. Paspot / Passport a) Mukasurat butiran diri pekerja / Foreign Worker’s details page b) Mukasurat Pengesahan Tarikh Ketibaan / Foreign Worker’s Date of Arrival page ii. Salinan Surat Kelulusan Visa / Photocopy o f Calling Visa D D M M Y Y Y Y iii. Laporan Perubatan dari negara asal (sekiranya ada) / Medical Report from country of origin (if available) Pembaharuan / Renewal 1. Dokumen asal / Original document i. Paspot asal / Original passport 2. Dokumen salinan / Photocopy document i. Sila lampirkan sali nan Paspot a sal Pekerja Asing - muka surat Butiran D iri & Pe rmit Kerja. Please attach a copy of original passport – Foreign Worker’s Details & Work Permit Page. 3. Kod Pekerja Asing / Foreign Worker’s Code W A. BUTIRAN PEKERJ A / WORKER’S DETAILS 1. Nama Pekerja Mengikut Paspot / Worker’s Name According to the Passport 2. Nombor Paspot (lama) / Passport Number (old) 3. Nombor Paspot baru (Jika ada) / New Passport Number (If any) Sila sertakan salinan nombor paspot baru / Please attach copy of new passport number 4. Sektor / Sector Pembantu Rumah / Domestic Perkhidmatan / Service Perkilangan / Manufacturing Perladangan /Plantation Pertanian /Agriculture Pembinaan / Construction B. BUTIRAN MAJIKAN / EMPLOYER’S DETAILS 1. Nama Syarikat / Nama Majikan Company’ s N ame / Employ er’s Na me 2. No. Pendaft aran Syarikat / No. Kad Pengenalan Majikan Company Registration No. / Employ er’s IC No. 3. No. Telefon / Tel No. / s k a F . o N . 4 Fax No. C. DOKTOR YANG DIPILIH OLEH MAJI KAN / SELECTION OF DOCTOR BY THE EMPLOYER 1. Nama Doktor / Doctor’s Name 2. Nama Klinik / Clinic’s Name 3. Bandar / Town 4. Kod Doktor / Doctor’s Code (jika ada/ if any) D PENGESAHAN PENDAFTARAN / ACKNOWL EDGEMENT OF REGISTRATION (TANDAKAN “ √” / TICK “ √” ) Saya/Kami Majikan / EmployerPekerja atau wakil syarik at / Agensi Pekerjaan / Pendaftar Bebas / Company Employee or Employment Agency Freelance Agent e v i t a t n e s e rp e R d e s i ro h t u A Saya /Kami dengan ini mengesahkan bahawa semua maklumat dan dokumen yang d iberikan bagi permohonan ini adalah sah, benar dan lengkap. Permohonan klinik/doktor di atas adalah pilihan saya/ kami. Saya /Kami faham dan b ersetuju dengan terma-terma dan s yarat-syarat yang dinyatakan di atas. I/We hereby confirm that all the inform ation and documents given are valid, true and complete. The requested clinic/doctor has been selected by me/us. I/We understand and agree with the terms and condition s as stated above. Tarikh tiba di Mala ysia / Date of arrival in Malaysia - - 1. Na ma / Name: 2. Tandatangan / Signature: 3. Jawatan / Designation: 4. No. Telefon / Tel No.: 5. No. Kad pengena lan atau No. Paspot / IC. No or Passport No. : 6. Tarikh / Date: 7. Cop syarikat / Company stamp:
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Foreign Worker Medical Examination Registration Form
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7/17/2019 Foreign Worker Medical Examination Registration Form
A-18-1, Level 18, Hampshi re Place Offi ce, 157 Hampshir e, 1 Jalan Mayang Sari, 50450 Kuala Lu mpur .Tel: 03-2782 8777 Fax: 03-2782 8778 www.fomema.com.my
BORANG PENDAFTARAN PEMERIKSAAN PERUBATAN PEKERJA ASINGFOREIGN WORKER’S MEDICAL EXAMINATION REGISTRATION FORM
BAYARAN PENDAFTARAN / PAYMENT FOR REGISTRATION
RM 190 (perempuan) atau RM 180 (lelaki) dalam bentuk Draf Bank, Kiriman Wang, Wang Pos, CIMB Clicks atau Kredit Kad melalui POS Online atas nama FOMEMA SDN. BHD.RM 190 (female) or RM 180 (male) in the form of Bank Draft, Money or Postal Order, CIMB Clicks or Credit Card through POS Online payable to FOMEMA SDN. BHD.
Bayaran pendaftaran TIDAK AKAN DIKEMBALIKAN. Payment for registration is NON REFUNDABLE.
Pemeriksaan kesihatan mesti dijalankan dalam tempoh 90 hari dari tarikh pendaftaran. The Medical Examination must be done within 90 days from the date of registration.
JENIS PENDAFTARAN / TYPE OF REGISTRATION (TANDAKAN “ √” / TICK “√” )
Sila bawa dokumen-dokumen berikut / Please bring the following documents:Pendaftaran kali pertama (Ketibaan baru) / First tim e registration (New arrival)1. Dokumen asal / Original document i. Paspot asal / Original passport2. Dokumen salinan / Photocopy documents
i. Paspot / Passporta) Mukasurat butiran diri pekerja / Foreign Worker’s details pageb) Mukasurat Pengesahan Tarikh Ketibaan / Foreign Worker’s Date of Arrival page
ii. Salinan Surat Kelulusan Visa / Photocopy of Calling Visa D D M M Y Y Y Y
iii. Laporan Perubatan dari negara asal (sekiranya ada) / Medical Report from country of origin (if available)
Pembaharuan / Renewal1. Dokumen asal / Original document
i. Paspot asal / Original passport 2. Dokumen salinan / Photocopy document
i. Sila lampirkan salinan Paspot asal Pekerja Asing - mukasurat Butiran Diri & Permit Kerja.Please attach a copy of original passport – Foreign Worker’s Details & Work Permit Page.
3. Kod Pekerja Asing / Foreign Worker’s Code W
A. BUTIRAN PEKERJA / WORKER’S DETAILS
1. Nama Pekerja Mengikut Paspot /Worker’s Name According to the Passport
2. Nombor Paspot (lama) / Passport Number (old)
3. Nombor Paspot baru (Jika ada) / New Passport Number (If any)Sila sertakan salinan nombor paspot baru / Please attach copy of new passport number
4. Sektor / Sector Pembantu Rumah / Domestic Perkhidmatan / Service Perkilangan / Manufacturing
Perladangan / Plantation Pertanian / Agriculture Pembinaan / Construction
B. BUTIRAN MAJIKAN / EMPLOYER’S DETAILS
1. Nama Syarikat / Nama MajikanCompany’ s Name / Employer’s Name
2. No. Pendaftaran Syarikat / No. Kad Pengenalan MajikanCompany Registration No. / Employ er’s IC No.
3. No. Telefon / Tel No. /skaF.oN.4 Fax No.
C. DOKTOR YANG DIPILIH OLEH MAJIKAN / SELECTION OF DOCTOR BY THE EMPLOYER
1. Nama Doktor / Doctor’s Name
2. Nama Klinik / Clinic’s Name
3. Bandar / Town
4. Kod Doktor / Doctor’s Code (jika ada/ if any) D
Saya/Kami Majikan / Employer Pekerja atau wakil syarikat / Agensi Pekerjaan / Pendaftar Bebas /Company Employee or Employment Agency Freelance Agent
evitatneser peRdesir ohtu A
Saya/Kami dengan ini mengesahkan bahawa semua maklumat dan dokumen yang d iberikan bagi permohonan ini adalah sah, benar danlengkap. Permohonan klinik/doktor di atas adalah pilihan saya/kami. Saya/Kami faham dan b ersetuju dengan terma-terma dan s yarat-syaratyang dinyatakan di atas. I/We hereby confirm that all the inform ation and documents given are valid, true and complete. The requestedclinic/doctor has been selected by me/us. I/We understand and agree with the terms and condition s as stated above.
Tarikh tiba di Malaysia / Date of arrival in Malaysia
- -
1. Nama / Name: 2. Tandatangan / Signature :
3. Jawatan / Designation : 4. No. Telefon / Tel No. :
5. No. Kad pengenalan atau No. Paspot / IC. No or Passport No.:
6. Tarikh / Date: 7. Cop syarikat / Company stamp:
7/17/2019 Foreign Worker Medical Examination Registration Form