NBC 461

INSTRUCTIONS:

 FILL OUT THIS FORM ACCURATELY AND LEGIBLY, TYPEWRITTEN OR HANDWRITTEN.

 FOR ADDITIONAL SPACE USE THE SAME SIZE OF BOND PAPER, FOLLOW THE SAME FORMAT.
 ALL CLAIMS MUST BE SUPPORTED WITH DOCUMENTS.
 THIS DOCUMENT IS TO BE SUBSCRIBED AND SWORN TO HENCE ALL PAGES MUST BEAR THE SIGNATURE OF THE FACULTY.

PERSONAL DATA SHEET

Name:
Last First Middle

Date of Birth: Sex: Civil Status:

Home Address: Telephone No.

Mailing Address:

College: Department:

Present Rank: Status of Appointment:

Annual Salary: Date of Last Appointment:

1.0 EDUCATIONAL QUALIFICATION (Maximum 85 pt.)
1.1 Highest Educational Qualification
1.1.1 Doctorate

Title of Degree Year Obtained School

Points:

1.1.2 Master’s Degree

Title of Degree Year Obtained School

Points:

1.1.3 LLB, MD

Title of Degree Year Obtained School

Points:

1.1.4 Diploma Course

Title of Degree Year Obtained School

 Points:

1.1.5 Bachelor’s Degree

Title of Degree Year Obtained School

Points:

1.2 Additional Equivalent Degree Earned

Title of Degree Year Obtained School

Points:

1.3 Additional Credits Earned Toward a Higher Degree

Title of Degree No. of Units as per Transcript of Records School

Points:

2.0 EXPERIENCE AND PROFESSIONAL SERVICES (Maximum 25 points)

2.1 Academic Experiences
2.1.1 Years of full time teaching in college, in research/extension

Inclusive Date SUC Position and Function

 Points:

2.1.2 Years of full time academic service in other types of institution

Inclusive Date SUC Position and Function

Points:

2.2 Administrative Experiences

2.2.1 Years of full time Administrative Designation

Inclusive Date SUC Position and Function

Points:

2.3 Industrial/Agricultural Experiences

2.3.2 Years of experience as Cooperating Teacher/Basic Education Teacher

Inclusive Date SUC Position and Function

Points:

3.0 PROFESSIONAL DEVELOPMENT ACHIEVEMENTS AND HONORS (Maximum 90 points)

3.1 Innovations, patented inventions, predications, other creative works (Maximum 30 points)
3.1.1 A. Inventions
 Title and Nature of Invention Patent Number Level (Inst., Nat., Reg., Local)

Points:
3.1.1 B. Discoveries

Nature of Discoveries Field

Points:

3.1.1 C. Creative Works

Nature of Creative Work Title Level (Inst., Nat., Reg., Local)

Points:

3.1.1 D. Innovations

Nature of Innovation Title Year

Points:

3.1.2 Books (Textbook, references) published within the last 10 years

Complete Title of the Book Copyright Date Role (author, co-author, etc.) Level (College/HS/Elem.)
 Points:

3.1.3 Published Scholarly Research, monographs, education technical articles, etc.

Complete Title of Article Journal where Article was Published Level (College/HS/Elem.)

Points:

3.1.4 Instructional Manual/Audio-Visual materials

Title Sponsoring Agency Level (Inst., Nat., Reg., Local) Inclusive Date

Points:
3.2 EXPERT SERVICES. TRAINING AND ACTIVE PARTICIPATION (Maximum 30pts)
3.2.1 Training and Seminars (Maximum 10 points)
3.2.1.1 Training Courses (Maximum 10 points)

Title Sponsoring Agency Level (Inst., Nat., Reg., Local) Inclusive Date

Points:
3.2.1.3 for Participation in conferences, seminars, workshops

Title Sponsoring Agency Level (Inst., Nat., Reg., Local) Inclusive Date

Points:

3.2.2 EXPERT SERVICES RENDERED (Maximum 20 pts)

3.2.2.1 Short-term consultant/expert in an activity

Title Sponsoring Agency Level (Inst., Nat., Reg., Local) Inclusive Date

Points:

3.2.2.2 Services rendered as Coordinator, Lecturer, Resource Person or Guest Speaker

Title Sponsoring Agency Level (Inst., Nat., Reg., Local) Inclusive Date
 Points:

3.2.2.3 Expert services as advisers in doctorate, masteral and undergraduate theses (Maximum 10points)

Title of Dissertation/Thesis Semester/School Year

Points:

3.2.2.4 Service as Reviewer/Examiner of the Professional Regulation Commission and Civil Service Commission

Title of Professional Examination Agency

Points:

3.2.2.5 Expert service in accreditation works

Title of Accreditation Board/Committee Agency

Points:

3.2.2.6 Expert service in Trade skill certification

Title of Trade Test Nature of participation (e.g. Trade Testing Officer)

 Points:

3.2.2.7 For every year of service as Coach/Trainor in Sports or adviser of accredited student organization

Nature Service Rendered Organization

Points:

3.3 Membership in professional organizations/honor societies and honors received (Maximum 10 points)
3.3.1 Individual Membership

Nature of Organization Date of Membership

Points:

3.3.2 Undergraduate Academic Honors

Honors Received Degree School Address

Points:

3.3.3 Scholarship/Fellowship

Title Nature and Level Date of Graduation

 Points:

3.4 Awards of Distinction

Title of Award Field of Service Organization that gave the Award Level (Inst., Nat., Reg., Local)

Points:

3.5 Community Outreach (Maximum 5 points)

Type of Voluntary Service Community/Barangay Inclusive Date

Points:
3.6 Professional Examination
3.6.1 Relevant Licensure/Professional Examinations (Maximum 10 pts)

Title of Professional Examination or Trade Skill Test Date

Points:

I hereby certify to the accuracy and correctness of these statements.

Signature of Faculty Member

SUBSCRIBED AND SWORN TO before me this _______________________ day of ____________________________________ 2011 affiant
exhibiting to me his/her Community Tax Certificate No. ________________________________ issued at Zamboanga City on ________________________.
Director for Administration