PERSONAL DATA SHEET NBC 461

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.
________________________________________________________________________
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

1.2

SPECIALIZATION

INSTITUTION

YEAR OBTAINED

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

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,
ARTICLES, FILMS,
INSTRUCTIONAL,
MATERIALS)

COMPLETE TITLE

ROLE

PUBLISHER

DATE OF
PUBLICATION

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 (INTL,
NATL, REGL,
LOCAL, INSTL

INCLUSIVE
DATES

B. CONFERECES, SEMINARS, ETC.

TITLE OF CONFERENCE

3.2.2
A.

SPONSORING AGENCY

INCLUSIVE DATES

EXPERT SERVICES
CONSULTANCY

NATURE/AREA OF
CONSULTANCY

COUNTRY

SPONSORING AGENCY

INCLUSIVE
DATES

B.

ACTIVE

PARTICIPATINNG

IN

TRAININNG.

WORKSHOPS,

CONFERENCES,

AS

COORDINATOR, LECTURER RESOURCES PERSON, GUEST SPEAKER

TITLE OF CONFERENCES,
SEMINARS, WORKSHOPS, ETC.

C.

NUMBER OF
PATICIPANTS

SPONSORING AGENCY

INCLUSIVE
DATES

FOR EXPERT SERVICES AS ADVISER IN DOCTORAL DISSERTATION AND

MASTERAL THESIS
TITLE OF PAPER

NATURE

INCLUSIVE DATES

D. 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

3.3.2

ACADEMIC HONORS RECEIVED

HONORS RECEIVED

3.3.3

DEGREE OBTAINED

INSTITUTION ADDRESS

SCHOLARSHIP/FELLOWSHIP

TITLE OF
SCHOLARSHIP

3.4

DATE OF MEMBERSHIP

NATURE (COMPETITIVE: INTL,

NATL, REGL, LOCAL) (NON
COMPETITIVE: INTL, REGL,
LOCAL)

SPONSORING AGENCY

INCLUSIVE
DATES

AWARDS OF DISTINCTION RECEIVED IN RECOGNITION OF ACHIEVEMENT IN

RELEVANT AREAS OF SPECIALIZATION/PROFESSIONAL/ ASSIGNMENT

TITLE OF AWARD
OF
DISTINCTION
(INSTRUCTIONAL
MATERIALS)

3.5

FIELD OF
SERVICES

GRANTEE
ORGANIZATION

LEVEL: INTL/
NATL/
REGL/
LOCAL

DATE

COMMUNITY OUTREACH: SERVICE ORIENTED PROJECTS PARTICIPATED IN THE

COMMUNITY
NAME OF PROJECT

3.6

PARTICIPATION
SERVICE

SPONSORING AGENCY

INCLUSIVE
DATES

PROFESSIONAL EXAMINATIONS
TITLE OF EXAMINATION

D.

RESEARCH

RATING

RECOMMENDATION

TRANSFORMED

DATE

TO

PUBLIC

BENEFITING TO THE COUNRTY AND OTHER CREATIVE WORKS

POLICY

COMPLETE TITLE OF
RESEARCH

E.

LEVEL; INTL,
NATL, REGL,
LOCAL, INSTL

SPONSORING AGENCY

INCLUSIVE
DATES

SUPERVISION, TUTORING OR COACHING OF GRADUATE SCIENTISTS AND

TECHNOLOGIES

NATURE AREA
SUPERVISION
TUTORING
COACHING

F.

OF
/
/

RESEARCH

COUNTRY

RESULTS

SPONSORING
AGENCY

APPLIED

OR

LEVEL: INTL/
NATL/ REGL/
LOCAL

UTILIZED

COMMERCIAL PROJECTS OR UNDERTAKING

IN

INCLUSIVE
DATES

INDUSTRIAL AND/OR

LEVEL; INTL,
NATL, REGL,
LOCAL, INSTL

COMPLETE TITLE OF
RESEARCH

SPONSORING AGENCY

INCLUSIVE
DATES

I HEREBY CERTIFY TO THE CORRECTNESS AND ACCURACY OF THE STATEMENTS.

______________________________________________
SIGNATURE OF FACULTY MEMBER

Subscribed
_____________________
______________________
______________________.

and

sworn

affiant

to

before

exhibiting

issued

at

to

me
me

this
his/her

__________________
Residence

day

Certificate

___________________________________

of
No.
on