g50 form (amended)
TRANSCRIPT
STAFF-IN-CONFIDENCE
PERSONAL PARTICULARS FORM
NOTE : 1. TYPE clearly.
2. Furnish the particulars in the Addendum if the family size exceeds 8 members.
3. Enter the words `Nil’ or `NA’ where applicable. Do not leave any space blank.
4. Entry of all Chinese names in Chinese characters is optional.
5. Sign on the dotted line at the right hand bottom of every page.
Proposed Post Substantive Appointment Ministry/Department Divisional Status
Present Post Substantive Appointment Ministry/Department Divisional Status
PART I PERSONAL PARTICULARS
Full Name in BLOCK LETTERSUnderline Surname If married woman, state maiden name
Mr ROSLY BIN MOHD.YUSOFF
Chinese Characters(Optional) Nil
Aliases
NilHanyu Pinyin
NilChinese Characters(Optional)
Nil
NRIC No. (e.g. S1234567A)
7436468
Citizenship
Malaysia
Citizenship Cert No.
Nil
Date of Issue YYYY/MM/DD
Nil
Date of Birth YYYY/MM/DD
1964/11/18
Place of Birth
Johore Bahru
Race/Dialect
Malay
Religion:Denomination:Place of worship:
MuslimNilTaiping, Perak
Other Citizenship or Permanent Residence currently held(Since when)
Nil
Sex:
Male
Marital Status
Married
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1,Kem Sungai Besi 04 04 57000
Home Tel No: Office Tel No: Cellular No: Pager No: E-Mail Address:
Nil Nil 013-3801811 Nil [email protected]
FOR FOREIGNERS ONLY
Type of Travel Document Held Date of Issue Place of Issue Date of Expiry
Nil Nil Nil Nil
Address in Country of Origin
NilFIN No.
Nil
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 1
STAFF-IN-CONFIDENCE
PART II COUNTRIES IN WHICH APPLICANT HAD RESIDED DURING THE PAST TEN YEARS
Period of Stay Address Country
From (Date) To (Date)
Nil Nil Nil Nil
PART III EDUCATIONAL QUALIFICATIONS IN CHRONOLOGICAL ORDER
Name of School/College/University Attended(Irrespective of whether they are foreign or local)
Country Duration of Course Results Attained(To state no. of passes for `O’ and `A’
Levels)Date Joined Date Left
SekolahMenengah Tasek Utara, Johor Bahru, Johor
Malaysia 1977 1979 Form 1 - Form 3
Sekolah Menengah Teknik, Johor Bahru, Johor
Malaysia 1980 1981 Form 4 - 5
Universiti Teknologi Malaysia, Kuala Lumpur Malaysia 1982 1985 Diploma in Civil Engineering
PART IV NATIONAL SERVICE RECORDS
National Service (NS)
Date of Enlistment
ORD NSF Rank Unit Vocation Date of Disruption
Date of Re-Enlistment
NS Status
N.A.
Reservist Status
N.A.
Nil
If you have not served full-time service, state reason1. MTE (Minimum Term Engagement)2. Exempted3. Not Applicable4. Part-time NS (State Period)
PART V KNOWLEDGE OF LANGUAGES AND DIALECTS
Written & Spoken Spoken Only
Bahasa Malaysia Bahasa Malaysia Bahasa Malaysia
PART VI HOBBIES AND RECREATIONAL ACTIVITIES
Play Golf and Bowling
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 2
STAFF-IN-CONFIDENCE
PART VII PREVIOUS AND PRESENT EMPLOYMENT IN CHRONOLOGICAL ORDER
Period of Employment Name And Address Of Employer As Well As Your Designation For Each Period of EmploymentFrom To
Mei (05) 1986
Dec (12) 1993
Name of Employer Pantas Edar Sdn. Bhd.
Address of Employer Damansara Utama, Petaling Jaya
Your Designation Site Supervisor
Jan (01) 1994
Jan (01) 1996
Name of Employer Tajol, Ho Consultant Sdn. Bhd.
Address of Employer Kuala Lumpur
Your Designation Clerk Of Work
Mac (03) 1996
Mac (03) 1998
Name of Employer Selangor Industrial Coporation Sdn. Bhd.
Address of Employer Shah Alam, Selangor
Your Designation Clerk Of Work / Site Supervisor
April (04) 1998
Dec (12) 2001
Name of Employer Hashim & Neh Sdn. Bhd.
Address of Employer Mont Kiara Sri Hartamas, Kuala Lumpur.
Your Designation Clerk Of Works
Feb (02) 2002
June (06) 2004
Name of Employer UMI-ROSS Project Management Sdn.Bhd. & URUSBUDI Consult Sdn. Bhd.
Address of Employer Kelana Jaya, Petaling Jaya, Selangor Darul Ehsan.
Your Designation Clerk Of Work
June (06) 2004
June (06) 2006
Name of Employer Strutech Engineering Consultant Sdn. Bhd. & RAH Properties Sdn. Bhd.
Address of Employer USJ Taipan, Subang Jaya, Selangor Darul Ehsan & Kg. Baru Kuala Lumpur
Your Designation Clerk Of Work
July (07) 2006
Feb (02) 2008
Name of Employer JPS Consulting Engineer Sdn. Bhd.
Address of Employer Sec 17, Petaling Jaya, Selangor Darul Ehsan.
Your Designation Clerk Of Work
August (08) 2008
February (02) 2009
Name of Employer Jurutera Konsult Maju Sdn. Bhd.
Address of Employer Dataran Prima Kelana jaya, Petaling jaya, Selangor Datul Ehsan.
Your Designation Clerk Of Work
Mac (03) 2009
April (04) 2010
Name of Employer SBB Perunding
Address of Employer Taman Kasturi, Balakong, Cheras, Selangor Darul Ehsan.
Your Designation Clerk Of Work
Mei (05) 2010
September (09) 2011
Name of Employer ZATH Perunding Sdn. Bhd.
Address of Employer Ipoh, Perak Darul Ridzuan
Your Designation Clerk Of Work
PART VIIIPREVIOUS AND CURRENT SUPERVISORS
Previous Supervisors Designation Period Tel No./Pager
Ir. Tan C.O.W Mei 2010
Current Supervisor Designation Since When Tel No./Pager
Ir. Eddie Ng C.O.W. Oct 2011 03-27019488
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 3
STAFF-IN-CONFIDENCE
PART IX PARTICULARS OF PARENTS, BROTHERS, SISTERS, SPOUSE AND ALL CHILDREN
State whether you are the only child : NO
If no, please indicate the number of : Brothers 03 Sisters 02
State whether you have any children : YES
If yes, please indicate the number of : Sons 02 Daughters 03
Furnish the particulars in the Addendum if the family size exceeds 8 members
Print only the Addendum page(s) if required to fill up from page 10 onwards
1) Full Name
Mohd. Yusoff Bin Mohd. SaidChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
390113-01-5353
Citizenship
Malaysian
Relationship
Father
Sex
Male
Occupation (if deceased, state so)
Retired (Officer)
Date of Birth YYYY/MM/DD 1939/01/13
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No.4 Jalan Lurah Utama, Kempas, Johor Bahru Nil Nil 81200
2) Full Name
Rokiah Bte AbdullahChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
431203-01-5360
Citizenship
Malaysian
Relationship
Mother
Sex
Female
Occupation (if deceased, state so)
Housewwife
Date of Birth YYYY/MM/DD 1943/12/03
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No. 4 Jalan Lurah Utama, Kempas Baru, Johor Bahru Nil Nil 81200
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 4
STAFF-IN-CONFIDENCE
3) Full Name
Ismail Bin Mohd. YusoffChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
631009-01-5640
Citizenship
Malaysian
Relationship
Brother
Sex
Male
Occupation (if deceased, state so)
Retired Navy Officer
Date of Birth YYYY/MM/DD 1963/10/09
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Lot 69 Taman Lagenda Villa 5, Kg Lajau, Wilayah Persekutuan, Labuan, Sabah
Nil Nil 87000
4) Full Name
Norhayati Bte Mohd. YusoffChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
660603-01-5580
Citizenship
Malaysian
Relationship
Sister
Sex
Female
Occupation (if deceased, state so)
Housewife
Date of Birth YYYY/MM/DD 1966/06/03
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No. 23 Jalan Anggerik 1/10, Taman Anggerik, Johor Bahru Nil Nil 81200
5) Full Name
Mohd. Hisham Bin Mohd. YusoffChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
680322-01-6083
Citizenship
Malaysian
Relationship
Brother
Sex
Male
Occupation (if deceased, state so)
Retired Army Officer
Date of Birth YYYY/MM/DD 1968/03/22
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No. 4 Jalan Lurah Utama, Kempas Baru, Johor Bahru Nil Nil 81200
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 5
STAFF-IN-CONFIDENCE
6) Full Name
Norhatasyah Bte Mohd. YusoffChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
790829-01-6258
Citizenship
Malaysian
Relationship
Sister
Sex
Female
Occupation (if deceased, state so)
Housewife
Date of Birth YYYY/MM/DD 1978/08/29
Place of Birth
Johor Bahru, Johor
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No.4 Jalan Lurah Utama, Johor Bahru Nil Nil 81200
7) Full Name
Mejar Haspalila Bte Hj. HassanChinese Characters(Optional)
Nil
Marital Status
Married
NRIC No.
T3003436
Citizenship
Malaysian
Relationship
Wife
Sex
Female
Occupation (if deceased, state so)
Army Officer
Date of Birth YYYY/MM/DD 1964/05/25
Place of Birth
Terengganu
Employer’s Name & Address
Angkatan Tentera Malaysia (ATM) / 74 Batalion Kor Perkhidmatan DiRaja (KPD) Kem Perdana Kem
Sungai Besi, 57000 Kuala LumpurHome Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
8) Full Name
Mohd Saiful Azzam Bin RoslyChinese Characters(Optional)
Nil
Marital Status
Single
NRIC No.
851228-11-5417
Citizenship
Malaysian
Relationship
Son
Sex
Male
Occupation (if deceased, state so)
Town Planner Lecturer
Date of Birth YYYY/MM/DD 1985/12/28
Place of Birth
Terengganu
Employer’s Name & Address
Universiti Teknologi Mara (UiTM) Seksyen 2, 40000 Shah Alam, Selangor Darul Ehsan
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
Please use the Addendum from Page 10 onwards if space is insufficient.
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 6
STAFF-IN-CONFIDENCE
PART X PARTICULARS OF ANY RELATIVES KNOWN TO BE WORKING IN FOREIGN GOVERNMENT ESTABLISHMENTS: EMBASSIES/HIGH COMMISSIONS/INTELLIGENCE SERVICES/ARMED FORCES/CIVIL SERVICE
1) Full Name
NilChinese Characters (Optional
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address*
Home Address
Block/House No. Street Code Level No.* Unit No.* Postal Code
2) Full Name
NilChinese Characters (Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address*
Home Address
Block/House No. Street Code Level No.* Unit No.* Postal Code
3) Full Name
NilChinese Characters (Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address*
Home Address
Block/House No. Street Code Level No.* Unit No.* Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 7
STAFF-IN-CONFIDENCE
PART XI MEMBERSHIP OF SOCIETIES, CLUBS AND ASSOCIATIONS, AND PROFESSIONAL BODIES
Name and Address of Societies/Clubs/Associations/Professional Bodies (in full) Date Joined Position Held
Nil
PART XII OWNERSHIP OF LOCAL AND OVERSEAS ASSETS (INCLUDING PROPERTIES/OTHER INVESTMENTS)
Description of Properties/Investments/AssetsCountry Date Purchased Estimated value
(S$)
Address (including district and lot nos. for properties)
Nil
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 8
STAFF-IN-CONFIDENCE
PART XIII PARTICULARS OF TWO REFEREES KNOWN TO APPLICANT FOR 2 YEARS OR MORE(The Referees should be Singapore residents and Non-Relatives, and are prepared to be interviewed)
Full Name in BLOCK LETTERSUnderline SurnameIf married woman, state maiden name
Mr SALLEHUDDUN BIN A. RAHMAN
Chinese Characters(Optional)
Nil
NRIC No.
600427-01-5367
Pager No. NilHome Tel No.
Nil
Sex
Male
Occupation
Officer
Cellular No. 012-7586609
In what capacity do you know him/her
Personal Friend
No. of Years Known
10
Name & Address of Employer
Jabatan Kerja Raya (JKR D) / Pejabat Jurutera Daerah, , 677 Jalan Petrie,
Johor Bahru
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
JKR1240 E Quarters JKR, Jalan Pengkalan Rinting, Johor Bahru Nil Nil 81200
Full Name in BLOCK LETTERSUnderline SurnameIf married woman, state maiden name
Mr IR NOR AZMAN BIN YAAKOB
Chinese Characters(Optional)
Nil
NRIC No.
620620-04-5179
Pager No. NilHome Tel No.
Nill
Sex
Male
Occupation
Resident Engineer M & E
Cellular No. 019-2132020
In what capacity do you know him/her
Personal Friend
No. of Years Known
3
Name & Address of Employer
J & A Associate Sdn. Bhd. / Suite C22, 2nd Floor, Block C, Plaza Pekeliling, No
2 Jalan Tun Razak, 50400 Kuala Lumpur
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
No.1 Laluan Meru Indah C2, Gerbang Meru Indah, Ipoh, Perak Darul Ridzuan
Nil Nil 30020
PART XIVDECLARATIONI give my consent for the relevant Government authorities to obtain and verify information from or with any source, as you deem appropriate for the assessment of my application for employment/suitability for a sensitive deployment and/or access to highly classified information. I also declare that the particulars stated above and in the Addendum are true and correct to the best of my belief and knowledge, and that I have not wilfully suppressed any material fact.
Signature of Applicant
Name Rosly Bin Mohd. Yusoff
NRIC No 641118-01-5057
Date YYYY/MM/DD
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 9
STAFF-IN-CONFIDENCE
Addendum
PART IX PARTICULARS OF PARENTS, BROTHERS, SISTERS, SPOUSE AND ALL CHILDREN
9) Full Name
Kapten Nur Husna Bazlin Bte RoslyChinese Characters(Optional)
Nil
Marital Status
Single
NRIC No.
T374313
Citizenship
Malaysian
Relationship
Daughter
Sex
Female
Occupation (if deceased, state so)
Air Force Pilot
Date of Birth YYYY/MM/DD 1987/06/20
Place of Birth
Terengganu
Employer’s Name & Address
Tentera Udara DiRaja Malaysia (TUDM) / No 1 Squadron, Pusat Latihan Terbang Tactical,
Pengkalan Udara Kuching, 93677 Kuching, SarawakHome Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
10) Full Name
Nor Izni Irsalina Bte RoslyChinese Characters(Optional)
Nil
Marital Status
Single
NRIC No.
890810-14-5808
Citizenship
Malaysian
Relationship
Daughter
Sex
Female
Occupation (if deceased, state so)
Student (Account)
Date of Birth YYYY/MM/DD 1989/08/10
Place of Birth
Kuala Lumpur
Employer’s Name & Address
Universiti Teknologi Mara (UiTM) Seksyen 2, 40000 Shaha Alam, Selangor Darul Ehsan
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
11) Full Name
Mohd Saiful Zulikram Bin RoslyChinese Characters(Optional)
Nil
Marital Status
Single
NRIC No.
940107-04-5429
Citizenship
Malaysian
Relationship
Son
Sex
Male
Occupation (if deceased, state so)
Student (Form 5)
Date of Birth YYYY/MM/DD 1994/01/07
Place of Birth
Melaka
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 10
STAFF-IN-CONFIDENCE
Addendum
12) Full Name
Nur Najihah Bte RoslyChinese Characters(Optional)
Nil
Marital Status
Single
NRIC No.
981005-14-5550
Citizenship
Malaysian
Relationship
Daughter
Sex
Female
Occupation (if deceased, state so)
Student (Form 1)
Date of Birth YYYY/MM/DD 1998/10/05
Place of Birth
Kuala Lumpur
Employer’s Name & Address
Nil
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
Block C1 Jalan Kedah 1, Kem Sungai Besi, Kuala Lumpur 04 04 57000
13) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
14) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 11
STAFF-IN-CONFIDENCE
Addendum
15) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
16) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
17) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 12
STAFF-IN-CONFIDENCE
Addendum
18) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
19) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
20) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 13
STAFF-IN-CONFIDENCE
Addendum
21) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
22) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
23) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 14
STAFF-IN-CONFIDENCE
Addendum
24) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
25) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
26) Full Name
NilChinese Characters(Optional)
Marital Status
NRIC No.
Citizenship
Relationship
Sex
Occupation (if deceased, state so)
Date of Birth YYYY/MM/DD
Place of Birth
Employer’s Name & Address
Home Address
Block/House No. Street Code Level No. Unit No. Postal Code
ISD/E-G50/01 STAFF-IN-CONFIDENCE ............................................... Page 15