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เอกสารหมายเลข 2

แบบสรปผลการปฏบตตนตามจรรยาบรรณผประกอบวชาชพทางการศกษา

เพอรบเครองหมายเชดชเกยรต “ครสดด” ประจ าป 2556

เขตพนทการศกษา .................................................. เขต .....................

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ชอ – นามสกล ...............................................................................................................

วน / เดอน / ปเกด ........................................................................... อาย..................ป

วฒการศกษา ..................................................................................................................

จาก ............................................................................................................................................................

ต าแหนง .....................................................................................................................................................

ชอสถานศกษา / หนวยงาน ........................................................................................................................

ทตง ............................................................................................................................................................

..........................................................................................................โทร. ..................................................

สงกด ..........................................................................................................................................................

ระยะเวลาการปฏบตงาน.......................................... ป

สรปผลการปฏบตตนตามจรรยาบรรณผประกอบวชาชพทางการศกษาทเดนทสด โดยแสดงใหเหนถงพฤตกรรมทไดรบการยกยองซงปรากฏหลกฐานทสามารถอางองได (ไมเกน 8 บรรทด)

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ภาพถาย

ขนาด

1 นว

เอกสารหมายเลข 3

แบบประวตผประกอบวชาชพทางการศกษาทไดรบการคดเลอก เพอรบเครองหมายเชดชเกยรต “ครสดด” ประจาป 2556

สงกด................................................................... ตอนท 1 ประวตของผทไดรบการคดเลอก

1. ชอ (นาย / นาง / นางสาว) ............................................... นามสกล .......................................................

2. เกดวนท .................... เดอน ......................................... พ.ศ. ........................ อาย ............................ป

3. ตาแหนงหนาทในปจจบน ............................................................................................................................ สถานททางาน ............................................................................................................................................ ตงอยเลขท ........................... ถนน .............................................. ตาบล / แขวง ..................................... อาเภอ / เขต ..................................... จงหวด ................................. รหสไปรษณย ................................ โทร .............................................

4. ทอยปจจบน เลขท ....................... ถนน ......................................... ตาบล / แขวง .................................. อาเภอ / เขต ..................................... จงหวด ................................. รหสไปรษณย ................................ โทร .............................................

5. ผทไดรบการคดเลอกม

ใบอนญาตประกอบวชาชพ ประเภท ................................ เลขท หมายเลขบตรประจาตวประชาชน

6. วฒการศกษา วฒ ป พ.ศ. ทสาเรจการศกษา ชอสถาบน

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7. เรมปฏบตหนาทคร ผบรหารสถานศกษา ผบรหารการศกษา และบคลากรทางการศกษาอน (ศกษานเทศก) ตงแตวนท ................ เดอน ................................ พ.ศ. ................... นบถงวนท 31 พฤษภาคม 2556 รวม ............................ ป ............................. เดอน ................................... วน

ภาพถาย

ขนาด

1 นว

- 2 -

8. ประวตหนาทการงาน ตงแตเรมตนจนถงปจจบน (ระบ/วน/เดอน/ป) ทเรมตนและสนสดของการดารง ตาแหนง และสถานทของแตละตาแหนง

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/ ตอนท 2...

- 3 - ตอนท 2 ผลการปฏบตตนตามจรรยาบรรณวชาชพทง 9 ขอ และขอใดขอหนงใน 9 ขอ ทเดนชดทสด ทสงผล

ใหปรากฏเปนทยอมรบของนกเรยน ผรวมงาน ผปกครองและชมชน และเปนผลของการอทศตน เพอประโยชนแกวชาชพครอยางสง ตลอดระยะเวลาของการปฏบตงานพรอมกบแนบหลกฐานอางอง ให เหนรองรอยการปฏบตตนตามจรรยาบรรณของวชาชพดงกลาว

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ขาพเจาขอรบรองวา ไมมกรณถกดาเนนการทางวนยมากอน หรอ อยในระหวางแตงตงกรรมการสอบสวน ทางวนย

ขาพเจาขอรบรองวาขอความดงกลาวขางตนน เปนความสตยจรงทกประการจงลงลายมอชอไวเปนหลกฐาน ลงชอ .................................................. เจาของประวต

(..........................................................................)

ขาพเจา (นาย / นาง / นางสาว) ................................................... ตาแหนง ........................................... เกยวของเปน ............................................. ขอรบรองวา ....................................................... มประวตการทางาน ดงกลาวขางตนจรง ลงชอ ............................................................... ผเสนอ

(.........................................................................) ตาแหนง....................................................................

ลงชอ ............................................................. ผรบรอง

(..........................................................................) ตาแหนง......................................................................

หมายเหต โปรดแนบสาเนาใบอนญาตประกอบวชาชพ และสาเนาสมดประวตการเปนคร เพอประกอบการพจารณาดวย

aqd wanirds:~u'u odlus:& Oa&U 0 a 0 ~ 0 9 4

I I 1

aqd wanisds:~Gu odlussiYu 0 %&u 0 I 0 wol4

a~~enu~sgan'~Z.aap~ 4 014

9. Qdrznou?.tnBwmanir4n~i w".adszwqiidgunnu i~u~ii lumsou%6~iazw"aui

i ~ r q i i o iiqnu mnui 3ndTausrsu ~iiilqq~ dainm~nu s'nlnwndrzlu.a&adGaurautiaz~m~ulunir w 4 d dnnraarzuaudrznid?~u6uiw ~z%1~11n~mrup1rai~ufl~z~"u

.#A a, 92 ~w ~ o 9 ~ ~ ~ l s z ~ i j u l ~ a z ~ ~ ~ a l ~ ~ ~ ~ d n 1 ~ a " n ~ m w " ~ ~ 1 0 ~ a v o ~ ~ ~ 1 ~ ~ ~ u n i s d ~ z ~ i j u ~ ~ u n a s

r i n l b o n l 8 ~ ~ ~ 1 1 n ~ o ~ ~ % 1 1 u ~ ~ ~ ~ ~ " n u s ~ c c q y ? t y 3 ~ultoqiia 7 ad sl s l w

1. glasumrds-liiu lAd~sJ"Gniurrrai~js~m~o~3~13wni~nisEn~1i 4 ~ 9 n dlriuArrR

%pa 9 48

d w u (asva) ........................................................... PIx~iun5'5un15nniaan

d d (adva) ......................... : ................... n55un-15 (asva) ............................................ n%5un13

( ............................................ ( ............................................ 1

d (asva) ............................................... nssuni5

( ............................................ 1

s w s Y A Y 4. dguawuinaaun3iu?uw"~vou $ob6qo?n Iaul~wkwadrzIuvu'

es3erinr3~aan'e$Ynrpf3ni3

3. $d~znou?vi%~miam5~n~i b ~ i n mnm milold .dauma"o d~mar?a l f i f i i a " q l o ~ l f i

%uhlaz~Yuu?msmuumuimp1w"id Tnolmonli.1

I I I

sqd wamr Jrzlu'u o~'lurz6u O~duu O W 0 woI4

4. diQu'ilQqinYa~tu mnui a"m~ussru dqsl2nZsu u-1rYoluiliil9u

d5:1s.a6io~asugiio~iaz~~n~aiau5a~

d d ...................... ...................... (asyo) ............................................... nssunis (asyo) ; n3suni~

............................................ ( .......................................... 1 ( )

A d (as%@ ........................................... nssunis (asvo) ............................................. nssuni3

( .............................................. ............................................ 1 ( )

'4 d (asvo) ............................................ nssunis (asyo) .............................................. nssunis

( ............................................. ............................................ ) ( 1

d B (asvo) ............................................... nssums (asvo) ............................................. nssums

( ............................................ ............................................ 1 ( )

5. lhzuuqa(¶issuIumsw"01s~~iwa~iu'~a~$iauds:n~u'i"~i3w

a ~ l l wanisdrz~Su atjlusz611 0 Zduu 0 "n 0 w a l l

d d (asyo) .............................................. nssunis (asvs) ............................................... nssunis

( ............................................ ( ............................................ )

d d ( a s ~ s ) .............................................. nssunis (awe) .............................................. nssunis

d d ( a s ~ 8 ) ............................................... nxiunis (asctrs) .............................................. nssunis

( ............................................. (. .......................................... .)

d d (as?@ .............................................. nsf unis ( a s v ~ ) .............................................. nssunis

( ............................................ ........................................... 1 (. )

A d (asllr~) ............................................... nssunis (asvo) ............................................... nssunir

(. ................ .: ........................... ............................................ 1 ( )

d d (as~o) ............................................. nssunis (asllro) ............................................... n3sunis

(. ............................................ ) ( ............................................ 1

d (asllra) ............................................ nssunis

(. ............................................ .)

B (asm) ............................................... nssunis

( ............................................ )