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 Mr ROSLY BIN MOHD.YUSOFF Chinese Character s (Optional) Nil Aliases Nil Hanyu Pinyin Nil Chinese Character s (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: Muslim Nil Taiping, 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 ISD/E-G50/01 STAFF-IN- CONFIDENCE ................................. .............. Page 1
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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:
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
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.