Republic of the Philippines NUEVA VIZCAYA STATE UNIVERSITY Bambang, Nueva Vizcaya PERSONAL DATA SHEET NBC 461

1 5 Cycle (July 1, 2007 to June 30, 2010)

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NOTE: THIS FORM WILL BE FILED BY THE FACULTY MEMBERS OF A STATE COLLEGE/UNIVERSITY INSTRUCTIONS: 1. 2. 3. 4. FILL OUT THIS FORM ACCURATELY AND LEGIBLY TYPEWRITTEN OR HANDWRITTEN. REFER TO ATTACHED NOTES FOR DETAILS. FOR ADDITIONAL SPACE USE THE SAME SIZE OF BOND PAPER, FOLLOW THE SAME FORMAT. ALL CLAIMS MUST BE SUPPORTED WITH RELEVANT DOCUMENTS. THIS DOCUMENT IS TO BE SUBMITTED AND SWORN TO, HENCE ALL PAGES MUST BEAR THE SIGNATURE OF THE FACULTY MEMBER. Sex: Tel. No.: Tel. No.: (078) 321-3037

Name: Date of Birth: Civil Status: Home Address: Mailing Address: College: Department: Present Rank/Sub-Rank: Status of Appointment: Annual Salary: Date of Last Appointment/NOSA:

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1.0 EDUCATIONAL QUALIFICATION 1.1 Highest relevant academic degree or educational attainment and educational equivalent degree earned related to the present position. DEGREE EARNED SPECIALIZATION INSTITUTION YEAR OBTAINED

1.2 Additional equivalent degree earned related to the present position. DEGREE EARNED SPECIALIZATION INSTITUTION YEAR OBTAINED

1.3 Additional credits earned towards an appropriate higher degree. Nature/Area Company/Agency Inclusive Dates

2.0 EXPERIENCE AND LENGTH OF SERVICE 2.1 Academic experience (includes full-time teaching, research, extension service, administrative experience and industrial experience). INCLUSIVE DATE POSITION HELD INSTITUTION ADDRESS

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2.2 Administrative Experience INCLUSIVE DATE POSITION HELD INSTITUTION/ADDRESS

2.3 Professional and Technical Experience INCLUSIVE DATE POSITION HELD INSTITUTION/ADDRESS

3.0 PROFESSIONAL DEVELOPMENT, ACHIEVEMENT AND HONORS 3.1 Discoveries and inventions 3.1.1 Discoveries, innovations, patented inventions, inventions and patent pending, publications and other creative works and research results. NATURE OF INNOVATIONS/INVENTIONS PATENT NUMBER YEAR PATENTED

3.1.2 3.1.4 Published books, research, monographs, articles, instructional manual; workbooks, films, compositions. Nature (books, articles, films, instructional materials) Complete Title Role Publisher Date of Publication

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3.2 For Expert Services, Training and Active Participation in Professional/Technical Activities 3.2.1 Training Courses and Seminars (Including academic, technical, industrial, agro-industrial and fishery training) 3.2.1.1.3.2.1.2 Training Title of Training Sponsoring Agency Level (Intl, Natl, Regl, Local/Instl) Inclusive Date

3.2.1.3

Conferences, Seminars, etc. Sponsoring Agency Level (Intl, Natl, Regl, Local/Instl) Inclusive Date

Title of Conferences/Seminars

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3.2.2 Expert Services 3.2.2.1 Consultancy Nature/Area of Consultancy

Country

Sponsoring Agency

Inclusive dates

3.2.2.2 For services rendered as trainer, coordinator, lecturer, resource person, guest speaker in conferences, workshops and/or training courses for professionals. Title of conference Seminar, Workshop, etc. Nature of Participants Sponsoring Agency Inclusive Dates

3.2.2.3 For Expert services as adviser in doctoral dissertation, masteral thesis, and undergraduate thesis. Title of Paper Nature

Inclusive Dates

3.2.2.4 For certified services (includes reviewer/examiner in PRC or CSC) Nature/Area Company/Agency

Inclusive Dates

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3.2.2.5

For expert services in accreditation and quality assurance work Nature/Area Company/Agency Inclusive Dates

For expert services as testing officer in trade skill certification Nature/Area Company/Agency Inclusive Dates

3.2.2.7

For expert services as coach trainer/Adviser of student organization Nature/Area Company/Agency Inclusive Dates

3.3 3.3.1

Membership in professional organizations/honor societies and honors received. Membership in Professional/honor societies Name of Organization Date of Membership

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3.3.2 Academic honors earned Honors Received Degree Obtained Institution Address

3.3.2.2

Graduate Degree Honors Received Degree Obtained Institution Address

3.3.3 Scholarship/Fellowship Title of Scholarship Nature (Competitive: Intl/Natl/Regl/Local) (Non-Competitive: Intl/Natl/Regl/Local) Sponsoring Agency Inclusive Dates

3.4

Awards of Distinction received in recognition of achievement in relevant areas of specialization/profession/assignment Title of Award of Distinction Field of Service Grantee Organization Level: International/National/ Regional/Local/Institutional

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3.5

Community Outreach: service oriented projects participated in the community Name of Project Participation/Service Sponsoring Agency Inclusive Dates

3.6

Professional Examination Title of Examination Rating Date

__________________________________ Signature of Faculty Member Subscribed and sworn to before me this _______ day of _____________. Affiant exhibiting to me his/her Residence Certificate No. __________________ issued at __________________________________on __________________________________.

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