Professional Documents
Culture Documents
NOTE: THIS FORMED WILL BE FIILED BY THE FACULTY MEMBERS OF A STATE COLLEGE/UNIVERSITY
INSTRUCTIONS:
1. FILL OUT THS FORM ACCURATELY AND LEGIBLY, TYPWRITTEN OR HANDWRITTEN.
2. FOR ADDITIONAL SPACE USE THE SAME SIZE OF BOND PAPERS, FOLLOW THE SAME FORMAT.
3. ALL CLAIMS MUST BE SUPPORTED WITH DOCUMENTS.
4. THIS DOCUMENT IS TO BE SUBCRIBED AND SWORN TO, HENCE ALL PAGES MUST BEAR THE SIGNATURE OF THE FACULTY MEMBER.
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PERSONAL DATA
NAME: _____
PATACSIL_______________________________________FREDERICK____________________________________FLORES___________________________________
Last
First
Middle
Date of Birth: _______Oct. 29, 1969________________________________ Sex: __Male___________________________ Civil Status ______Married___________________________________
Home Address: _Maticmatic Sta. Barbara, Pangasinan_______________________________________________________ Tel. No. __________________________________________________
Mailing Address: ____________________________________________________________________________________ _ Tel. No. _________________________________________________
College/Campus: __Urdaneta City Campus_________________________________________________________________
Department: ________________________________________________________________________________________
Present Rank/Sub-Rank: _______________________________________________________________________________
Status Appointment: __________________________________________________________________________________
Annual Salary: _______________________________________________________________________________________
Date of Last Appointment: _____________________________________________________________________________
_________________________
DEPARTMENT CHAIRMAN
Year Obtained
School
Points ______________
1.2 Additional Equivalent Degree
Title of Degree
Year Obtained
School
Points ______________
1.3 Additional Credits Earned Towards a Higher Degree
Degree
No. of Units as per Transcript of Records
School
School Year
Points ______________
1.3.1.1 Relevant credits earned in the same level as higher degree
Subjects
School
Units
Points ______________
______________________
DEPARTMENT CHAIRMAN
SUC
Points ______________
2.1.2 Years of Full time academic in other types of institutions
Inclusive Dates
Institutions
Position
Level
(Elem. High School, College)
Points ______________
2.2.1 Full-time Administrative Experience
Inclusive Dates
Institution
Position
Points ______________
_____________________
DEPARTMENT CHAIRMAN
Institution
Position
Points ______________
2.3.2 Experience as Basic Education teacher
Inclusive Dates
Institution
Position
Points ______________
3.0 PROFESSIONAL DEVELOPMENT / ACHIEVEMENT/HONORS
3.1 Innovations, patented Inventions, publications and other creative works
3.1.1
A. Inventions
Title & Nature of Inventions
Patent Score
Level
(International, National, Regional, Local)
Points ______________
______________________
DEPARTMENT CHAIRMAN
3.1.1 B. Discoveries
Nature of Discovery
Field
Points ______________
3.1.1 C. Creative Works
Nature of Creative Work
Title
Level of recognition
(International, National, Regional, Local)
Points ______________
3.1.1 D. Innovation
Nature of innovation
Title
Year
Points ______________
_____________________
DEPARTMENT CHAIRMAN
3.1.2
Copyright Date
Role
(Author, Co- Author, etc)
Level
(College, High School, Elementary)
Points ______________
3.1.3 Published scholarly research, monographs, technical articles
Complete Title of Article
Level
(International, National, Regional, Local)
Points ______________
3.1.4 Instructional manual, Audio-visual materials
Nature of Instructional material
Title
Role
(Single Author, Co- Author, Etc)
Points ______________
______________________
DEPARTMENT CHAIRMAN
Training Course
Title of Training
Sponsoring Agency
Level
(International, National, Regional, Local)
Inclusive Dates
Points ______________
3.2.1.3 Active Participation in Conference, Seminars, Workshop
Title of Conference
Nature of Participation
Sponsoring Agency
Inclusive Dates
Points ______________
3.2.2.1 Consultancy
Nature/Area of Consultancy
Country
Sponsoring Agency
Inclusive Dates
Points ______________
______________________
DEPARTMENT CHAIRMAN
3.2.2.2
Service as Coordinator, Lecturer, Resource Person, Guest Speaker, In Training, Conferences, etc.
Nature of Participation
Sponsoring Agency
Inclusive Dates
Points _____________
3.2.2.3
Year/Semester
Points _____________
3.2.2.4
Place
Sponsoring Agency
Dates
Points _____________
_____________________
DEPARTMENT CHAIRMAN
3.2.2.5 Certified Work Experience other then teaching, related to present position/function
Nature / Area
Inclusive Dates
Points _____________
3.3
Nature of Membership
(Full or Associate or Officeship)
Inclusive Dates
Points _____________
3.3.2 Undergraduate Honors Earned
Honor Received
Degree
School / Address
Points _____________
_____________________
DEPARTMENT CHAIRMAN
Sponsoring Agency
Points _____________
3.4 Awards of Distinction
Title of award of Distinction
Field of service
Level
(Int., Nat, reg. Local)
Points _____________
_______________________
DEPARTMENT CHAIRMAN
Participation/ service
Agency
Inclusive Dates
Points ____________
3.6 Professional Examinations
Title of Examination
Date
Rating
Place of Examination
Points ____________
I hereby certify to the correctness and accuracy of
these statement.
_________________________________________
Signature of faculty
SUBSCRIBED AND SWORN TO before me this_______ day of _________________________, 200__, affiant
exhibiting to me his/her Community Tax Certificate No.__________ issued at ______________________ on _______________________.
_________________________________
Administrative Officer
_______________________
DEPARTMENT CHAIRMAN