CONTINUING PROFESSIONAL DEVELOPMENT FORM

(PKB Form)

Certification Bureau
2008
 1. Personal Data / General
Period : 20 … … s/d 20 … …
Full Name
Place & Date of Birth LATEST
No. KTA PHOTO
No. IP Certificate
Colleges/ Technology
Colleges
Home Institution (Agency/Company) 3 X 4 cm
Institution Name :
Title at the institution :
Address

City : Post Code : City : Post Code :

Communication Telephone : Facsimile : Telephone : Facsimile :

Telex : Telex :
Other communication Mobile phone : E-Mail :

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2. Post-Graduate Study (1.1)

Name & Address Filed by AP

Title Received Major Total of
Of University Title of Final Tutor Name and Address
No. and Graduation Department/ Study
include Phone number, Fax, Paper (if available) A B C
Month / Year Field Units
E-mail

Total

Proofs: - Diplomas: (available □ / n.a. □)

- Academic Transcript
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 - Abstract of final paper

3. Courses (1.2)

Name & Address Filed by AP

Of Organizer
No. Type of Courses Date Subject Matter Duration
with Phone number, Fax, A B C
E-mail

Total

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Proofs : - Courses Schedule and Syllabus (available / n.a.)
- Certificate or Letter informing the accomplishment of the courses with good result

4. Formal Job Training (1.3)

Name & Address Filed by AP

Type of Formal Organizer
No. Date Subject Matter Duration
Job Training with Phone Number, Fax, A B C
E-mail

Total

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Proofs : - Formal Job Training Schedule and Syllabus (available / n.a.)
- Certificate or Letter informing the accomplishment of training activities with good result

5. Self-Learning (2.1)

Name and Address of Filed by AP

Type of Self Date and Title of Self Learning Instructor with Phone
No. Reading Materials
Learning activity Duration activity numbers, Fax, A B C
E-mail

Total

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Proofs: - Extended Abstract or Executive Summary

6. Work Related Studies (2.2)

Name and Address Instructor Filed by AP

Type of Work Date and Title of Work Related
No. with Phone number, Fax, Reading Materials
Related Studies Duration Studies A B C
E-mail

Total

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Proofs: - Extended Abstract or Executive Summary

7. Participate in Profession Meetings (3.1)

Duration of Filed by AP
Topic of Profession Place and Date of Name of Profession Duties / Function at the
No. Profession
Meetings Profession Meetings Meeting Organizer Profession Meeting A B C
Meeting (hours)

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 Total

Proofs : - Certificate
- Brochure / Invitation

8. Participation in Organizing Committee (3.2)

Duration of Filed by AP
Type of Organizing Organizing Name of Task Assigning Function in
No. Type of activity
Committee Activity Committee Institution Organizing Committee A B C
Activity

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 Total

Proofs : - Brochure showing topic and meeting subject titles

- Letter of Assignment / Document showing organizing committee formation
- Official Certificate / Expression of Gratitude

9. Internal Technical Report (4.1)

Topic of Presentation Filed by AP

Title of Presentation Name of Task Assigning
No. and Internal Technical Role in Presentation
and Internal Technical Report Institution A B C
Report

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 Total

Proofs : - Brochure/program containing subject title and name of speakers

- Executive Summary or Photocopy of Technical Report

10. Presentation at Technical Meetings (4.2)

No Topic of Presentation at Title of Presentation Name Institution Filed by AP

Role in Presentation
. Professional Meetings at Technical Meetings Task Assigning A B C

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 Total

Proofs : - Brochure / program which contains name of speakers

- Letter of Assignment
- Official Certificate / Expression of Gratitude

11.a. Profession Meetings Paper (4.3)

Type of Profession Filed by AP

Total of
No Title of Paper at Profession Place and Date of Name of Meetings Meetings (Local,
Participants in
. Meetings Profession Meetings Organizer National, A B C
Meetings
International)

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 Total

Proofs : - Cover and Table of Content of Proceedings

- Photocopy of Paper (for Paper)

11.b. Magazine Articles (4.4)

Type of Publication Filed by AP

National Journal without
No
Article Topic Title of Magazine accreditation; Accredited National
. A B C
Journal; Accredited International
Journal

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 Total

Proofs: - Sample Copy or

- Photocopy of Magazine Cover and Photocopy of Writing

12. Book Writing (4.4.5)

Type of Book / Monograph / Standard and Filed by AP

No. Title of Writing Field of Profession Total of Pages
Code / Patent / Seminars Proceeding A B C

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 Total

Proofs: - Sample Copy or

- Photocopy of Book / Monograph / Standard and Code / Patent / Seminars Presiding

13. Lecturing (4.6)

Lecturing Type Filed by AP

Place and Date of Duration Total of
No. (Lecturer / Guest Lecturer / Name of Institution/ Employer
activity (hours) Participants A B C
Mentor / Tutor)

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 Total

Proofs : - Assignment Letter

- Schedule and Syllabus

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14. Expert or Resource Person (5.1)

Types / Role as Expert / Place and Date Name Institution/ Filed by AP

No.
Resource Person As Expert / Resource Person Employer A B C

Total

Proofs : - Certificate
- Assignment Letter / Invitation
- Letter of Appreciation

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15. Professional Association Governing Board Member (5.2)

Name of Profession Association/ Address with Phone number; Fax; Function / Title at Profession Term Periods Filed by AP
No.
Institution E-mail Association/ Institution (years) A B C

Total

Proofs : - Certificate
- Assignment Letter

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17. Recipient of Honours; Awards; etc. (5.3)

Honours/Award Received Filed by AP

No. Type of Honours/ Award Institution / Givers of Honours / Award
(year) A B C

Total
GRAND TOTAL

Proofs - Certificate

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