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PERSONAL DATA SHEET

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

1.0 EDUCATIONAL QUALIFICATIONS


1.1 Highest Degree Obtained
Title of Degree

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

2.0 ACADEMIC EXPERINCE AND LENGTH OF SERVICE


NOTE: Attach SERVICE RECORD
2.1.1 Years of Full time teaching in college, in research/extensions
Inclusive Dates

SUC

Position and Function

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

2.3.1 Full time industrial/agricultural/teaching experience


Inclusive Dates

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 No. Patent Panding

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

Books (textbooks, references) published within the last 10 years


Complete Title of Book

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

Journal where Article was Published

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

3.2 Expert services, trainings, active participation


3.2.1

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.

Title of conferences, seminar, workshops,etc

Nature of Participation

Sponsoring Agency

Inclusive Dates

Points _____________
3.2.2.3

Advisorship of dissertation, thesis


Title of Dissertation/Thesis

Year/Semester

Points _____________
3.2.2.4

Certified Reviewer/Examiner in PRC/CS


Title, Nature, Area of Work

Place

Sponsoring Agency

Dates

Points _____________

_____________________
DEPARTMENT CHAIRMAN

3.2.2.5 Certified Work Experience other then teaching, related to present position/function
Nature / Area

Company, Agency, etc

Inclusive Dates

Points _____________
3.3

MEMBERSHIP IN PROFESSIONAL ORGANIZATION, ETC.


3.3.1 Current Individual Membership
Nature of Organization
(Learned, Honor, Professional/Scientific)

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

3.3.3 Scholarship/ Fellowship


Title of Scholarship

Nature of Level, Doctoral, Masteral


Degree or Non-degree granting
competitive Non-Competitive

Date of graduation/ Completion

Sponsoring Agency

Points _____________
3.4 Awards of Distinction
Title of award of Distinction

Field of service

Organizational that Gave


the Award

Level
(Int., Nat, reg. Local)

Points _____________

_______________________
DEPARTMENT CHAIRMAN

3.5 Community outreach


3.5.1 Service-oriented Project
Nature of Project

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