PERSONAL DATA SHEET – NBC 461 2016 GUIDELINES
NOTE: THE FACULTY MEMBERS OF A STATE COLLEGE/UNIVERSITY WILL FILL THIS
FORM
INSTRUCTION:
1. FILL OUT THIS FORM ACCURATELY AND LEGIBLY (TYPEWRITTEN OR HAND
WRITTEN) REFER TO ATTACHED NOTES FOR DETAILS.
2. FOR ADDITIONAL SPACE, USE THE SAME SIZE BOND PAPER, FOLLOW THE SAME
FORMAT.
Name:
_______________________________________________________________________
Date: Sex:
_______________________________________________________________________
Civil Status:
________________________________________________________________________
Home Address: Tel No.
________________________________________________________________________
1
E-mail Address: Mobile No.
________________________________________________________________________
College/University:
________________________________________________________________________
College/Department:
________________________________________________________________________
Present Rank:
________________________________________________________________________
Status of Appointment:
________________________________________________________________________
Annual Salary:
________________________________________________________________________
Date of Last Appointment/NOSA:
1.0 EDUCATIONAL QUALIFICATION
1.1 HIGHEST RELEVANT ACADEMIC DEGREE OR EDUCATIONAL
ATTAINMENT AND ADDITIONAL EQUIVALENT DEGREE EARNED TO THE
PRESENT POSITION.
DEGREE EARNED SPECIALIZATION INSTITUTION YEAR OBTAINED
1.2 ADDITIONAL CREDITS EARNED TOWARDS AN APPROPRIATE HIGHER
DEGREE
BACCALAUREATE MASTERAL DOCTORAL
2.0 EXPERIENCE AND LENGTH OF SERVICE
1.3 SERVICE RECORDED. INCLUDES FULL-TIME TEACHING, RESEARCH,
EXTENSION SERVICE AND INDUSTRIAL EXPERIENCES
INCLUSIVE DATE POSITION HELD INSTITUTION ADDRESS
A. RESEARCH RECOMMENDATION TRANSFORMED TO PUBLIC POLICY
BENEFITING TO THE COUNRTY AND OTHER CREATIVE WORKS
COMPLETE TITLE OF LEVEL; INT’L, SPONSORING AGENCY INCLUSIVE
RESEARCH NAT’L, REG’L, DATES
LOCAL, INST’L
B. SUPERVISION, TUTORING OR COACHING OF GRADUATE SCIENTISTS AND
TECHNOLOGIES
NATURE AREA OF COUNTRY SPONSORING AGENCY LEVEL: INT’L/ INCLUSIVE
SUPERVISION / NAT’L/ REG’L/ DATES
TUTORING / LOCAL
COACHING
C. RESEARCH RESULTS APPLIED OR UTILIZED IN INDUSTRIAL AND/OR
COMMERCIAL PROJECTS OR UNDERTAKING
COMPLETE TITLE OF LEVEL; INT’L, SPONSORING AGENCY INCLUSIVE
RESEARCH NAT’L, REG’L, DATES
LOCAL, INST’L
4 D. RESEARCH RECOMMENDATION TRANSFORMED TO PUBLIC POLICY
BENEFITING TO THE COUNRTY AND OTHER CREATIVE WORKS
COMPLETE TITLE OF LEVEL; INT’L, SPONSORING AGENCY INCLUSIVE
RESEARCH NAT’L, REG’L, DATES
LOCAL, INST’L
E, SUPERVISION, TUTORING OR COACHING OF GRADUATE SCIENTISTS AND
TECHNOLOGIES
NATURE AREA OF COUNTRY SPONSORING LEVEL: INT’L/ INCLUSIVE
SUPERVISION / AGENCY NAT’L/ REG’L/ DATES
TUTORING / LOCAL
COACHING
F, RESEARCH RESULTS APPLIED OR UTILIZED IN INDUSTRIAL AND/OR
5 COMMERCIAL PROJECTS OR UNDERTAKING
COMPLETE TITLE OF LEVEL; INT’L, SPONSORING AGENCY INCLUSIVE
RESEARCH NAT’L, REG’L, DATES
LOCAL, INST’L
3.0 PROFESSIONAL DEVELOPMENT, ACHIEVEMENT AND HONORS
NATURE OF INNOVATION/INVENTION PATENT NUMBER YEAR PATENTED
3.1.2 – 3.1.5 PUBLISHED BOOKS, RESEARCH MONOGRAPHS, ARTICLES,
INSTRUCTIONAL MANUALS, FILMS, COMPOSITIONS
NATURE (BOOKS, COMPLETE TITLE ROLE PUBLISHER DATE OF
ARTICLES, FILMS, PUBLICATION
INSTRUCTIONAL,
MATERIALS)
6
3.2 EXPERT SERVICES, TRAINING AND ACTIVE PARTICIPATION IN
PROFESSIONAL/TECHNICAL ACTIVITIES
3.2.1 TRAINING COURSES AND SEMINARS (INCLUDING ACADEMIC, TECHNICAL,
INDUSTRIAL, AND FISHERY TRAINING)
A. TRAINING
TITLE OF TRAINING SPONSORING AGENCY LEVEL (INT’L, INCLUSIVE
NAT’L, REG’L, DATES
LOCAL, INST’L
B. CONFERECES, SEMINARS, ETC.
TITLE OF CONFERENCE SPONSORING AGENCY INCLUSIVE DATES
3.2.2 EXPERT SERVICES
C, CONSULTANCY
NATURE/AREA OF COUNTRY SPONSORING AGENCY INCLUSIVE
CONSULTANCY DATES
D. 3.2.2.2. ACTIVE PARTICIPATINNG IN TRAININNG. WORKSHOPS, CONFERENCES, AS
COORDINATOR, LECTURER RESOURCES PERSON, GUEST SPEAKER
TITLE OF CONFERENCES, NUMBER OF SPONSORING AGENCY INCLUSIVE
SEMINARS, WORKSHOPS, ETC. PATICIPANTS DATES
E. 3.2.2.3.FOR EXPERT SERVICES AS ADVISER IN DOCTORAL DISSERTATION AND
MASTERAL THESIS
TITLE OF PAPER NATURE INCLUSIVE DATES
F .(3.2.2.4-3.2.2.7).FOR CERTIFIED SERVICES (INCLUDES REVIEWER/EXAMINAR IN
PRC OR CSC), ACCRREDITATION, TRADE SKILL CERTIFICATION, SERVICES AS
COACH/TRAINER, ADVISER OF STUDENT ORGANIZATION
NATURE AREA COMPANY/AGENCY INCLUSIVE DATES
3.3 MEMBERSHIP IN PROFESSIONAL ORGANIZATION/HONORS SOCIETIES AND
HONORS RECEIVED
3.3.1 MEMBERSHIP IN PROFESSIONAL/HONOR SOCIETIES
NAME OF ORGANIZATION DATE OF MEMBERSHIP
3.3.2 ACADEMIC HONORS RECEIVED
HONORS RECEIVED DEGREE OBTAINED INSTITUTION ADDRESS
3.3.3 SCHOLARSHIP/FELLOWSHIP
TITLE OF NATURE (COMPETITIVE: INT’L, SPONSORING AGENCY INCLUSIVE
SCHOLARSHIP NAT’L, REG’L, LOCAL) (NON DATES
COMPETITIVE: INT’L, REG’L,
LOCAL)
3.4 AWARDS OF DISTINCTION RECEIVED IN RECOGNITION OF ACHIEVEMENT IN
RELEVANT AREAS OF SPECIALIZATION/PROFESSIONAL/ ASSIGNMENT
TITLE OF AWARD FIELD OF GRANTEE LEVEL: INT’L/ DATE
OF DISTINCTION SERVICES ORGANIZATION NAT’L/
(INSTRUCTIONAL REG’L/
MATERIALS) LOCAL
3.5 COMMUNITY OUTREACH: SERVICE ORIENTED PROJECTS PARTICIPATED IN
THE COMMUNITY
NAME OF PROJECT PARTICIPATION SPONSORING AGENCY INCLUSIVE
SERVICE DATES
10
3.6 PROFESSIONAL EXAMINATIONS
TITLE OF EXAMINATION RATING DATE
I HEREBY CERTIFY TO THE CORRECTNESS AND ACCURACY OF THE
STATEMENTS.
______________________________________________
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
______________________.
11
