CONTINUING PROFESSIONAL DEVELOPMENT FORM (PKB Form) Certification Bureau 2015
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1 CONTINUING PROFESSIONAL DEVELOPMENT FORM (PKB Form) Certification Bureau 2015
2 1. Personal Data / General Full Name Place & Date of Birth KTA IP Certificate Colleges/ Technology Colleges Address Period : 20 s/d 20 LATEST PHOTO H o m e Institution (Agency/Company) 3 X 4 cm Institution Name : Title at the institution : City : Post Code : City : Post Code : Communication Telephone : Facsimile : Telephone : Facsimile : Telex : Telex : Other communication Mobile phone : Continuing Professional Development Form Page 1 of 17
3 2. Post-Graduate Study (1.1) Title Received and Graduation Month / Year Major Department/ Field Name & Address Of University include Phone number, Fax, of Study Units Title of Final Paper Tutor Name and Address (if available) Proofs: - Diplomas: (available / n.a. ) - Academic Transcript - Abstract of final paper Continuing Professional Development Form Page 2 of 17
4 3. Courses (1.2) Type of Courses Date Name & Address Of Organizer with Phone number, Fax, Subject Matter Duration Proofs : - Courses Schedule and Syllabus (available / n.a.) - Certificate or Letter informing the accomplishment of the courses with good result Continuing Professional Development Form Page 3 of 17
5 4. Formal Job Training (1.3) Type of Formal Job Training Date Name & Address Organizer with Phone Number, Fax, Subject Matter Duration Proofs : - Formal Job Training Schedule and Syllabus (available / n.a.) - Certificate or Letter informing the accomplishment of training activities with good result Continuing Professional Development Form Page 4 of 17
6 5. Self-Learning (2.1) Type of Self Learning activity Date and Duration Title of Self Learning activity Name and Address of Instructor with Phone numbers, Fax, Reading Materials Proofs: - Extended Abstract or Executive Summary Continuing Professional Development Form Page 5 of 17
7 6. Work Related Studies (2.2) Type of Work Related Studies Date and Duration Title of Work Related Studies Name and Address Instructor with Phone number, Fax, Reading Materials Proofs: - Extended Abstract or Executive Summary Continuing Professional Development Form Page 6 of 17
8 7. Participate in Profession Meetings (3.1) Topic of Profession Meetings Place and Date of Profession Meetings Name of Profession Meeting Organizer Duration of Profession Meeting (hours) Duties / Function at the Profession Meeting Proofs : - Certificate - Brochure / Invitation Continuing Professional Development Form Page 7 of 17
9 8. Participation in Organizing Committee (3.2) Type of Organizing Committee Activity Duration of Organizing Committee Activity Name of Task Assigning Institution Type of activity Function in Organizing Committee Proofs : - Brochure showing topic and meeting subject titles - Letter of Assignment / Document showing organizing committee formation - Official Certificate / Expression of Gratitude Continuing Professional Development Form Page 8 of 17
10 9. Internal Technical Report (4.1) Topic of Presentation and Internal Technical Report Title of Presentation and Internal Technical Report Name of Task Assigning Institution Role in Presentation Proofs : - Brochure/program containing subject title and name of speakers - Executive Summary or Photocopy of Technical Report Continuing Professional Development Form Page 9 of 17
11 10. Presentation at Technical Meetings (4.2) No. Topic of Presentation at Professional Meetings Title of Presentation at Technical Meetings Name Institution Task Assigning Role in Presentation Proofs : - Brochure / program which contains name of speakers - Letter of Assignment - Official Certificate / Expression of Gratitude Continuing Professional Development Form Page 10 of 17
12 11.a. Profession Meetings Paper (4.3) No. Title of Paper at Profession Meetings Place and Date of Profession Meetings Name of Meetings Organizer of Participants in Meetings Type of Profession Meetings (Local, National, International) Proofs : - Cover and Table of Content of Proceedings - Photocopy of Paper (for Paper) Continuing Professional Development Form Page 11 of 17
13 11.b. Magazine Articles (4.4) No. Article Topic Title of Magazine Type of Publication National Journal without accreditation; Accredited National Journal; Accredited International Journal Proofs: - Sample Copy or - Photocopy of Magazine Cover and Photocopy of Writing Continuing Professional Development Form Page 12 of 17
14 12. Book Writing (4.4.5) Title of Writing Type of Book / Monograph / Standard and Code / Patent / Seminars Proceeding Field of Profession of Pages Proofs: - Sample Copy or - Photocopy of Book / Monograph / Standard and Code / Patent / Seminars Presiding Continuing Professional Development Form Page 13 of 17
15 13. Lecturing (4.6) Lecturing Type (Lecturer / Guest Lecturer / Mentor / Tutor) Place and Date of activity Name of Institution/ Employer Duration (hours) of Participants Proofs : - Assignment Letter - Schedule and Syllabus Continuing Professional Development Form Page 14 of 17
16 14. Expert or Resource Person (5.1) Types / Role as Expert / Resource Person Place and Date As Expert / Resource Person Name Institution/ Employer Proofs : - Certificate - Assignment Letter / Invitation - Letter of Appreciation Continuing Professional Development Form Page 15 of 17
17 15. Professional Association Governing Board Member (5.2) Name of Profession Association/ Institution Address with Phone number; Fax; Function / Title at Profession Association/ Institution Term Periods (years) Proofs : - Certificate - Assignment Letter Continuing Professional Development Form Page 16 of 17
18 17. Recipient of Honours; Awards; etc. (5.3) Type of Honours/ Award Institution / Givers of Honours / Award Honours/Award Received (year) GRAND TOTAL Proofs - Certificate Continuing Professional Development Form Page 17 of 17
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