G50 Form (Amended)

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 LETTERS Underline Surname If married woman, state maiden name Aliases
Mr ROSLY BIN MOHD.YUSOFF

Hanyu Pinyin
Chinese Characters
(Optional)
Nil
Nil
NRIC No. (e.g. S1234567A) Citizenship
Nil
Citizenship Cert No.
Chinese Characters
(Optional)
Nil YYYY/MM/DD Nil
Date of Issue
7436468
Date of Birth
Malaysia
Place of Birth
Nil
Race/Dialect Religion: Denomination: Place of worship: Marital Status
YYYY/MM/DD
1964/11/18
Johore Bahru
Sex:
Malay
Muslim Nil Taiping, Perak
Other Citizenship or Permanent Residence currently held (Since when)
Nil
Home Address Block/House No. Street Code
Male
Married
Level No.
Unit No.
Postal Code
Block C1
Home Tel No: Nil
Jalan Kedah 1,Kem Sungai Besi

Office Tel No: Nil Cellular No: 013-3801811 Pager No: Nil
04
04
E-Mail Address:
57000
roslymohd@hotmail.com
FOR FOREIGNERS ONLY

Type of Travel Document Held Date of Issue Place of Issue Date of Expiry
Nil
Address in Country of Origin
Nil Nil
Nil
Nil
FIN No.
Nil
ISD/E-G50/01
STAFF-IN-CONFIDENCE
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Page 1
STAFF-IN-CONFIDENCE
PART II
COUNTRIES IN WHICH APPLICANT HAD RESIDED DURING THE PAST TEN YEARS
Address Country
Period of Stay From (Date) To (Date)
Nil PART III
Nil
Nil
Nil
EDUCATIONAL QUALIFICATIONS IN CHRONOLOGICAL ORDER

Country Duration of Course Date Joined Date Left Results Attained
(To state no. of passes for `O and `A Levels)
Name of School/College/University Attended

(Irrespective of whether they are foreign or local)
SekolahMenengah Tasek Utara, Johor Bahru, Johor Sekolah Menengah Teknik, Johor Bahru, Johor Universiti Teknologi Malaysia, Kuala Lumpur PART IV
Malaysia Malaysia Malaysia
1977 1980 1982
1979 1981 1985
Form 1 - Form 3 Form 4 - 5 Diploma in Civil Engineering
NATIONAL SERVICE RECORDS

Date of Enlistment ORD NSF Rank Unit Vocation Date of Disruption Date of ReEnlistment
National Service (NS)
Nil
NS Status
N.A.
Reservist Status
N.A.
If you have not served full-time service, state reason 1. MTE (Minimum Term Engagement) 2. Exempted 3. Not Applicable 4. 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
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STAFF-IN-CONFIDENCE
PART VII PREVIOUS AND PRESENT EMPLOYMENT IN CHRONOLOGICAL ORDER

Period of Employment From To
Name And Address Of Employer As Well As Your Designation For Each Period of Employment
Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Name of Employer Address of Employer Your Designation Pantas Edar Sdn. Bhd. Damansara Utama, Petaling Jaya Site Supervisor Tajol, Ho Consultant Sdn. Bhd. Kuala Lumpur Clerk Of Work Selangor Industrial Coporation Sdn. Bhd. Shah Alam, Selangor Clerk Of Work / Site Supervisor Hashim & Neh Sdn. Bhd. Mont Kiara Sri Hartamas, Kuala Lumpur. Clerk Of Works UMI-ROSS Project Management Sdn.Bhd. & URUSBUDI Consult Sdn. Bhd. Kelana Jaya, Petaling Jaya, Selangor Darul Ehsan. Clerk Of Work Strutech Engineering Consultant Sdn. Bhd. & RAH Properties Sdn. Bhd. USJ Taipan, Subang Jaya, Selangor Darul Ehsan & Kg. Baru Kuala Lumpur Clerk Of Work JPS Consulting Engineer Sdn. Bhd. Sec 17, Petaling Jaya, Selangor Darul Ehsan. Clerk Of Work Jurutera Konsult Maju Sdn. Bhd. Dataran Prima Kelana jaya, Petaling jaya, Selangor Datul Ehsan. Clerk Of Work SBB Perunding Taman Kasturi, Balakong, Cheras, Selangor Darul Ehsan. Clerk Of Work ZATH Perunding Sdn. Bhd. Ipoh, Perak Darul Ridzuan Clerk Of Work
Mei (05) 1986 Jan (01) 1994 Mac (03) 1996 April (04) 1998 Feb (02) 2002 June (06) 2004 July (07) 2006 August (08) 2008 Mac (03) 2009 Mei (05) 2010
Dec (12) 1993 Jan (01) 1996 Mac (03) 1998 Dec (12) 2001 June (06) 2004 June (06) 2006 Feb (02) 2008 February (02) 2009 April (04) 2010 September (09) 2011
PART VIII PREVIOUS AND CURRENT SUPERVISORS

Previous Supervisors Designation Period Tel No./Pager
Ir. Tan
Current Supervisor
C.O.W
Designation
Mei 2010
Since When

Tel No./Pager
Ir. Eddie Ng
C.O.W.
Oct 2011
03-27019488
ISD/E-G50/01
STAFF-IN-CONFIDENCE
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STAFF-IN-CONFIDENCE
PART IX
PARTICULARS OF PARENTS, BROTHERS, SISTERS, SPOUSE AND ALL CHILDREN
State whether you are the only child : If no, please indicate the number of : State whether you have any children : If yes, please indicate the number of :
NO
Brothers
03
Sisters
02
YES
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. Said

Relationship
Chinese Characters (Optional)
Marital Status
NRIC No.
Nil
Sex
Married
Citizenship
Occupation (if deceased, state so)
390113-015353
Malaysian
Date of Birth
Father
Place of Birth
Male
Employers Name & Address
Retired (Officer)
YYYY/MM/DD 1939/01/13
Johor Bahru, Johor
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 Abdullah

Citizenship Relationship
Marital Status
NRIC No.
Nil
Married
Sex
431203-015360
Malaysian
Date of Birth
Mother
Place of Birth
Female
Housewwife
YYYY/MM/DD 1943/12/03
Johor Bahru, Johor
Nil
No. 4
Jalan Lurah Utama, Kempas Baru, Johor Bahru
Nil
Nil
81200
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
3)
Full Name
Ismail Bin Mohd. Yusoff

Relationship
Marital Status
NRIC No.
Nil
Sex
Married
Citizenship
631009-015640
Malaysian
Date of Birth
Brother
Place of Birth
Male
Retired Navy Officer
YYYY/MM/DD 1963/10/09
Johor Bahru, Johor
Nil
Lot 69
Taman Lagenda Villa 5, Kg Lajau, Wilayah Persekutuan, Labuan, Sabah
Nil
Nil
87000
4)
Full Name
Norhayati Bte Mohd. Yusoff

Relationship
Marital Status
NRIC No.
Nil
Sex
Married
Citizenship
660603-015580
Malaysian
Date of Birth
Sister
Place of Birth
Female
Housewife
YYYY/MM/DD 1966/06/03
Johor Bahru, Johor
Nil
No. 23
Jalan Anggerik 1/10, Taman Anggerik, Johor Bahru
Nil
Nil
81200
5)
Full Name
Mohd. Hisham Bin Mohd. Yusoff

Marital Status
NRIC No.
Nil
Married
Sex
680322-016083
Malaysian
Date of Birth
Brother
Place of Birth
Male
Retired Army Officer
YYYY/MM/DD 1968/03/22
Johor Bahru, Johor
Nil
No. 4
Jalan Lurah Utama, Kempas Baru, Johor Bahru
Nil
Nil
81200
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
6)
Full Name
Norhatasyah Bte Mohd. Yusoff

Relationship
Marital Status
NRIC No.
Nil
Sex
Married
Citizenship
790829-016258
Malaysian
Date of Birth
Sister
Place of Birth
Female
Housewife
YYYY/MM/DD 1978/08/29
Johor Bahru, Johor
Nil
No.4
Jalan Lurah Utama, Johor Bahru
Nil
Nil
81200
7)
Full Name
Mejar Haspalila Bte Hj. Hassan

Marital Status
NRIC No.
Nil
Married
T3003436
Sex
Malaysian
Date of Birth
Wife
Place of Birth
Female
Army Officer
YYYY/MM/DD 1964/05/25
Terengganu
Angkatan Tentera Malaysia (ATM) / 74 Batalion Kor Perkhidmatan DiRaja (KPD) Kem Perdana Kem Sungai Besi, 57000 Kuala Lumpur
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 Rosly

Marital Status
NRIC No.
Nil
Single
Sex
851228-115417
Malaysian
Date of Birth
Son
Place of Birth
Male
Town Planner Lecturer
YYYY/MM/DD 1985/12/28
Terengganu
Universiti Teknologi Mara (UiTM) Seksyen 2, 40000 Shah Alam, Selangor Darul Ehsan
Block C1
04
04
57000
Please use the Addendum from Page 10 onwards if space is insufficient.
ISD/E-G50/01
STAFF-IN-CONFIDENCE
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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 Nil
Relationship Chinese Characters (Optional Marital Status NRIC No.
1) Full Name
Citizenship Sex
Date of Birth
Place of Birth Employers Name & Address*
YYYY/MM/DD
Home Address Block/House No. Street Code Level No.* Unit No.* Postal Code
2) Full Name
Nil
Marital Status
NRIC No.
Sex
Date of Birth
YYYY/MM/DD
3) Full Name
Nil
Relationship
Marital Status
NRIC No.
Citizenship Sex
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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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)
Country Description of Properties/Investments/Assets Date Purchased Estimated value (S$)
Address (including district and lot nos. for properties)
Nil
ISD/E-G50/01
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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 LETTERS Underline Surname If married woman, state maiden name
Chinese Characters (Optional) NRIC No.
Mr SALLEHUDDUN BIN A. RAHMAN
Nil
Occupation
600427-01-5367
Pager No.
Nil
Home Tel No. Nil
Sex
Male
Name & Address of Employer
Officer
Cellular No. 012-7586609 In what capacity do you know him/her Personal Friend Home Address Block/House No. Street Code Level No. Unit No. Postal Code No. of Years Known 10
Jabatan Kerja Raya (JKR D) / Pejabat Jurutera Daerah, , 677 Jalan Petrie, Johor Bahru
JKR1240 E
Quarters JKR, Jalan Pengkalan Rinting, Johor Bahru
Nil
Nil
NRIC No.
81200
Full Name in BLOCK LETTERS Underline Surname If married woman, state maiden name
Mr IR NOR AZMAN BIN YAAKOB
Nil
Occupation
620620-04-5179
Pager No.
Nil
Home Tel No. Nill
Sex
Male
Name & Address of Employer J & A Associate Sdn. Bhd. / Suite C22,
2n
Resident Engineer M & E
Cellular No. 019-2132020 In what capacity do you know him/her Personal Friend Home Address Block/House No. Street Code Level No. Unit No. Postal Code No. of Years Known 3
d Floor, Block C, Plaza Pekeliling, No
2 Jalan Tun Razak, 50400 Kuala Lumpur
No.1
Laluan Meru Indah C2, Gerbang Meru Indah, Ipoh, Perak Darul Ridzuan
Nil
Nil
30020
PART XIVDECLARATION
I 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 NRIC No Date YYYY/MM/DD
Rosly Bin Mohd. Yusoff 641118-01-5057
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
Addendum
PART IX
9) Full Name
PARTICULARS OF PARENTS, BROTHERS, SISTERS, SPOUSE AND ALL CHILDREN Kapten Nur Husna Bazlin Bte Rosly
Chinese Characters (Optional) Marital Status NRIC No.
Nil
Single
T374313
Citizenship
Relationship
Sex
Malaysian
Date of Birth
Daughter
Place of Birth
Female
Air Force Pilot
YYYY/MM/DD 1987/06/20
Terengganu
Tentera Udara DiRaja Malaysia (TUDM) / No 1 Squadron, Pusat Latihan Terbang Tactical, Pengkalan Udara Kuching, 93677 Kuching, Sarawak
Block C1
04
04
57000
10) Full Name
Nor Izni Irsalina Bte Rosly

Marital Status
NRIC No.
Nil
Single
Sex
890810-145808
Malaysian
Date of Birth
Daughter
Place of Birth
Female
Student (Account)
YYYY/MM/DD 1989/08/10
Kuala Lumpur
Universiti Teknologi Mara (UiTM) Seksyen 2, 40000 Shaha Alam, Selangor Darul Ehsan
Block C1
04
04
57000
11) Full Name
Mohd Saiful Zulikram Bin Rosly

Relationship
Marital Status
NRIC No.
Nil
Sex
Single
Citizenship
940107-045429
Malaysian
Date of Birth
Son
Place of Birth
Male
Student (Form 5)
YYYY/MM/DD 1994/01/07
Melaka
Nil
Block C1
04
04
57000
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
Addendum
12) Full Name
Nur Najihah Bte Rosly

Relationship
Marital Status
NRIC No.
Nil
Sex
Single
Citizenship
981005-145550
Malaysian
Date of Birth
Daughter
Place of Birth
Female
Student (Form 1)
YYYY/MM/DD 1998/10/05
Kuala Lumpur
Nil
Block C1
04
04
57000
13) Full Name
Nil
Marital Status
NRIC No.
Sex
Date of Birth
Place of Birth Employers Name & Address
YYYY/MM/DD
14) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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Addendum
15) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
16) Full Name Nil

Marital Status
NRIC No.
Sex
Date of Birth
YYYY/MM/DD
17) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
Addendum
18) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
19) Full Name
Nil
Marital Status
NRIC No.
Sex
Date of Birth
YYYY/MM/DD
20) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
Addendum
21) Full Name Nil
Relationship Chinese Characters (Optional) Marital Status NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
22) Full Name
Nil
Marital Status
NRIC No.
Sex
Date of Birth
YYYY/MM/DD
23) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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STAFF-IN-CONFIDENCE
Addendum
24) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
25) Full Name
Nil
Marital Status
NRIC No.
Sex
Date of Birth
YYYY/MM/DD
26) Full Name
Nil
Relationship
Marital Status
NRIC No.
Sex
Citizenship
Date of Birth
YYYY/MM/DD
ISD/E-G50/01
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STAFF-IN-CONFIDENCE

PERSONAL PARTICULARS FORM

Ministry/Department Divisional Status

PART I PERSONAL PARTICULARS

Mr ROSLY BIN MOHD.YUSOFF

Nil YYYY/MM/DD Nil

Muslim Nil Taiping, Perak

Other Citizenship or Permanent Residence currently held (Since when)

Jalan Kedah 1,Kem Sungai Besi

FOR FOREIGNERS ONLY

Period of Stay From (Date) To (Date)

Nil PART III

EDUCATIONAL QUALIFICATIONS IN CHRONOLOGICAL ORDER

Name of School/College/University Attended

Malaysia Malaysia Malaysia

1977 1980 1982

1979 1981 1985

Form 1 - Form 3 Form 4 - 5 Diploma in Civil Engineering

NATIONAL SERVICE RECORDS

National Service (NS)

KNOWLEDGE OF LANGUAGES AND DIALECTS

PART VI HOBBIES AND RECREATIONAL ACTIVITIES

PART VII PREVIOUS AND PRESENT EMPLOYMENT IN CHRONOLOGICAL ORDER

PART VIII PREVIOUS AND CURRENT SUPERVISORS

PARTICULARS OF PARENTS, BROTHERS, SISTERS, SPOUSE AND ALL CHILDREN

Mohd. Yusoff Bin Mohd. Said

Chinese Characters (Optional)

Occupation (if deceased, state so)

Johor Bahru, Johor

Jalan Lurah Utama, Kempas, Johor Bahru

Rokiah Bte Abdullah

Chinese Characters (Optional)

Occupation (if deceased, state so)

Johor Bahru, Johor

Jalan Lurah Utama, Kempas Baru, Johor Bahru

Ismail Bin Mohd. Yusoff

Chinese Characters (Optional)

Occupation (if deceased, state so)

Retired Navy Officer

Johor Bahru, Johor

Taman Lagenda Villa 5, Kg Lajau, Wilayah Persekutuan, Labuan, Sabah

Norhayati Bte Mohd. Yusoff

Chinese Characters (Optional)

Occupation (if deceased, state so)

Johor Bahru, Johor

Jalan Anggerik 1/10, Taman Anggerik, Johor Bahru

Mohd. Hisham Bin Mohd. Yusoff

Chinese Characters (Optional)

Occupation (if deceased, state so)

Retired Army Officer

Johor Bahru, Johor

Jalan Lurah Utama, Kempas Baru, Johor Bahru

Norhatasyah Bte Mohd. Yusoff

Chinese Characters (Optional)

Occupation (if deceased, state so)

Johor Bahru, Johor