Appendix 6

COMMITMENT LETTER

Date :
To : Vice President of Medical
Employer :
Address :
Tel No : : (H) (O)
(H/P) (Fax)

Name of Foreign Worker :

Worker Code :
Worker’s 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 worker’s medical condition described above, I/we wish to
employ/continue employing him/her as __________________________ and his/her duties are as
follows:-

1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________

In light of the medical condition described above I/we confirm and assure FOMEMA that I/we will
not assign him/her any tasks that would aggravate the foreign worker’s medical condition
described above and put him/her/others health at risk. Additionally, I confirm that I/we will bear
any and all cost relating directly or indirectly towards the medical management of his/her medical
condition.

I/We confirm that FOMEMA shall not be held responsible in any manner whatsoever, arising out
of FOMEMA’s certification of the above named foreign worker as being suitable for employment
in Malaysia despite the medical condition described above. I/we further undertake to hold
FOMEMA harmless from any loss or liability arising from this decision and agree to indemnify and
keep FOMEMA from any loss or liability arising from this decision.

_________________
Authorized signature

Name : __________________

NRIC : ___________________

Employer’s Stamp (For Company only): ____________

(This form is to be filled up by the registered employer and verified by examining doctor. The filled-up form is to be
faxed or emailed to FOMEMA. Fax No: 03-27828773 / 03-27828774 Email: appeal@fomema.com.my)

Version 2.0 CONFIDENTIAL