APPEAL FORM
(Signature is not required for the online version of the Appeal Form as it shall be
substituted with an acknowledgment prior to online submission)
Appendix 4
I, the employer of the below-mentioned employee who has been certified unsuitable for employment
after undergoing a medical examination at the below-mentioned clinic would like to request for a review
of the medical examination result ("appeal process"). I acknowledge that the decision of the Appeal
Committee of FOMEMA shall be final and I agree unreservedly to abide by it. I undertake to hold FOMEMA
harmless from any loss or liability arising from this appeal including the spread of any infectious diseases
by the said employee; and I further agree to indemnify and keep FOMEMA and/or its directors,
shareholders and employees indemnified from any loss or liability arising from this appeal. I undertake to
bear any and all cost of this appeal and acknowledge that this appeal process may take up to four (4)
weeks from the time of its submission. I hereby consent and authorize FOMEMA to process my personal
data for the purpose of appeal process in accordance with the Personal Data Protection Act (PDPA) 2010
and any applicable Malaysian laws.
Saya, majikan bagi pekerja yang dinyatakan di bawah yang telah disahkan tidak sesuai untuk bekerja
selepas menjalani pemeriksaan kesihatan di klinik yang dinyatakan di bawah ingin meminta semakan
keputusan pemeriksaan perubatan ("proses rayuan"). Saya mengakui bahawa keputusan Jawatankuasa
Rayuan FOMEMA adalah muktamad dan saya bersetuju tanpa syarat untuk mematuhinya. Saya berjanji
untuk memastikan FOMEMA tidak dipertanggungjawabkan daripada sebarang kerugian atau liabiliti yang
timbul daripada proses rayuan ini termasuklah penyebaran sebarang penyakit berjangkit oleh pekerja
tersebut dan saya seterusnya bersetuju untuk menanggung rugi dan memastikan FOMEMA dan/atau
pengarah, pemegang saham dan pekerjanya dilindungi daripada sebarang kerugian atau liabiliti yang
timbul daripada rayuan ini. Saya berjanji untuk menanggung semua kos rayuan ini dan mengakui
bahawa proses rayuan ini mungkin mengambil masa sehingga empat (4) minggu dari masa
permohonan rayuan. Saya dengan ini mengizinkan dan memberi kuasa kepada FOMEMA untuk
memproses data peribadi saya bagi tujuan proses rayuan menurut Akta Perlindungan Data Peribadi
(PDPA) 2010 dan mana-mana undang-undang Malaysia yang berkenaan.
Date:
09/12/2025
Tarikh:
Name of Employer:
AEON DELIGHT (MALAYSIA) SDN BHD
Nama Majikan:
Contact No.:
Nombor Untuk 0392811224
Dihubungi:
Email Address:
ADMFOREIGNWORKERMANAGEMENT@[Link]
Alamat Emel:
Detail of Employee
Butiran Pekerja
Name of Foreign Worker: Worker Code:
SARDER TUHIN W44S301489
Nama Pekerja Asing: Kod Pekerja:
Passport No.: Country of Origin:
A17258548 BANGLADESH
No. Pasport: Negara Asal:
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Gender: Date of Birth:
LELAKI 01/01/1999
Jantina: Tarikh Lahir:
Examination Date: Certification Date:
26/11/2025 28/11/2025
Tarikh Pemeriksaan: Tarikh Perakuan:
Unsuitable Reason: Pemeriksaan x-ray dada ke atas pekerja ini mendapati penemuan tidak
Sebab Tidak Lulus: normal.
I declare that all information provided is true and accurate and by initiating this appeal, I agree to
FOMEMA's Terms of Service and Privacy Policy.
By proceeding, I acknowledge and accept the following:
1. The RM15 appeal admin fee is strictly non-refundable, while other fees (e.g. clinic, laboratory or
specialist fees) may be refundable, subject to the status of the appeal process.
2. No refund will be granted if the foreign worker has visited any appeal panel or more than 30 days
have passed since the Appeal Payment Date.
3. If the appeal case is closed due to the investigation report not being submitted within 30 days from
the Appeal Payment Date, a new full payment will be required to re-initiate the appeal process.
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