8011-ADS 2012 Intake Application Form

8/6/2019 8011-ADS 2012 Intake Application Form

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Australian Development Scholarships2012 Intake Application Form

Instructions

Please print neatly using block letters (huruf cetak) and black ink

Before completing this form, you must read the Australia Development Scholarships Handbook (The Handbook)

and your Countrys profile, available on the AusAID Website (see below) or from the AusAID/Managing

Contractors office in Indonesia. Brief information about the program is also included in this application form. Also

see www.adsindonesia.or.id

You must complete all fields marked with an * and all relevant sections.

This application must be completed in English.

For Yes or No questions, indicate your response with an X in the appropriate box.

Three (3) copies of this form and ofall attached documents must be received by 26 August 2011 at the

Australia Awards Office at Gedung Wirausaha, 7th

Floor. Jl. H.R. Rasuna Said Kav.C-5

Kuningan, Jakarta 12940.

DO NOT send this application to universities or other institutions in Australia.

Australian Development Scholarships will be offered only to those whose course of study will contribute

to the long-term development needs of Indonesia. A list of the development priorities is available under

Choosing a Course of Study on page 3 of this application form.

AusAIDs website includes a list of Australian Universities that may receive Development Scholarship awardees.

Course of study information is available directly from the Universities websites or the Commonwealth Register of

Institutions and Courses for Overseas Students (CRICOS) website (see below).

You may provide two preferences for courses of study. You should consider two Australian universities rather

than two courses at the same university, just in case you do not meet the admissibility requirements of the first

Australian university.

If your application is successful, you will be required to sign a Contract with the Commonwealth of Australia and

be bound by conditions of the scholarship. A full list of the conditions is contained in this application form (page

27 - 28) and in the Handbook. Please note that AusAID reserves the right to change these conditions at any time.

Submitting this application does not guarantee that you will receive a Scholarship.

If you do not receive an invitation to an interview from the Australia Awards Office by mid-December, you should

assume that your application has been unsuccessful.

Before applying, all Public sector applicants are required to have section 23 of the form completed by the

relevant training or foreign cooperation bureau or their university rector (whichever is applicable).

Applicants in the Open category are not required to fill in section 23. Their applications are to be submitted

directly to the Australia Awards Office at the address above.

Applicants must not fill in section 25. This section is for use by the Ministry of State Secretariat of the Republic of

Indonesia (SetNeg) and refers only to selected candidates.

In cases where information supplied by candidates is found to be inaccurate or incorrect, an award offer may be

revoked without notice.

The closing date is 26 August 2011

Applications should be submitted as early as possible


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General Information NotesAustralian Development Scholarships (ADS) provide opportunities for Indonesians to study in Australia atPOSTGRADUATE level.

Up to four hundred scholarships are expected to be awarded in 2012 for commencement in 2012/2013.Candidates must undertake study in one of the four areas of development priority (see page 3).

ADS are offered in two main categories: Public Sector Category and Open Category.

Public sector applicants are employees from Government organizations, state universities and state ownedenterprises. Their applications must be approved by training or foreign cooperation bureaus (BKLN) of their local or

central agencies before being submitted to the ADS Program Office. Public sector candidates from governmentagencies outside Jakarta may apply directly to the ADS Program Office with the approval of their relevant Kakanwil orKadinas. Calon Pegawai Negeri Sipil are not eligible to apply.

Open Category applicants are from private organisations and universities and this category is also open to recentuniversity graduates. No prior Government approval is required for people applying in the Open Category, andapplications are to be submitted directly to the Australia Awards Office. They require, where relevant, theendorsement of the agency, institution or private university in which the applicant is working or studying. Applicationsare submitted directly to the Australia Awards Office.

Public servants (Pegawai Negeri) cannot apply in the Open category.

A third category (Targeted) exists for candidates who are identified by their organisations in consultation with theADS Program. Candidates within this category must be identified by their home organization and must not apply tothe ADS Program independently of their employer.

`Targeted Category' candidates are employed by organisations which are identified by the Government of Indonesia

and Government of Australia (through AusAID) as being strategically aligned with the Development priorities of theGovernment of Indonesia.

Scholarships are for full-time study for a Masters or Doctorate degree from Australian tertiary institutions. Thescholarship provides up to nine months full-time language and academic preparation in Indonesia. Students mustachieve satisfactory results in this training to be able to continue their scholarships.

Applications from people with disabilities or from people in organisations working with the disabled areencouraged to apply.

Women and candidates in provinces within the geographic focus of AusAID's Country Strategy (see page 4) are alsoencouraged to apply.

EligibilityIN GENERAL CANDIDATES MUST:

be an Indonesian citizen and not have permanent residence in Australia or New Zealand

not be married or engaged to a person who is eligible to hold Australian or New Zealand citizenship or permanent

resident status, at any stage of the application, selection, mobilisation processes or while on-scholarship in

Australia

satisfy Australian Government requirements for international student entry to Australia (health, character etc)

not hold or have held a Government of Australia Scholarship to study outside Indonesia in the 24 months

preceding the application 24 months to be calculated from the date of arrival back in Indonesia to the

Scholarship application closing date

be applying to commence a new course of study and not be seeking support through ADS for a course already

commenced in Australia.

be able to take up the scholarship in the year for which it is offered

be able to satisfy all requirements of the Department of Immigration and Citizenship (DIAC) for an AusAID student

visa and

be able to satisfy the admission requirements of the Australian university at which the Scholarship is to be

undertaken.


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SPECIFICALLY, CANDIDATES MUST:

be applying for courses that fall within the areas of development priority (see Choosing a Course of Study below)

at the time of application, be no more than 42 years of age

have a Grade Point Average (GPA) of at least 2.9 on a scale of maximum 4.0 (or 2.75 for applicants from

geographic focus of AusAID Country Strategy only, see page ii) and an English language proficiency of at least

5.0 in IELTS (or 500 in paper-based TOEFL or 39 in Internet based TOEFL). The IELTS or TOEFL result must be

current (a test result obtained in 2010 or 2011 will be considered current). No other English language test

(including TOEFL prediction test) results will be accepted. Contact details of test centre must be provided for

verification of TOEFL test results.

already hold an undergraduate degree, if applying for a Masters

already have a Masters, if applying for a Doctorate

apply for a degree at a level higher than their current highest qualification

if applying for a Doctorate, applicants will be restricted to staff of universities, higher education institutions,

research institutes, key policy makers and targeted candidates in other agencies associated with AusAID activities

it is highly desirable for Doctorate applicants to have a letter of support from an Australian university for their

proposed field of study

answer all relevant questions on the application form

be willing and available to undertake full-time (Monday - Friday 0800-1600) English for Academic Purposes

(EAP) training in Indonesia prior to studying in Australia, if offered a scholarship.

Choosing a Course of StudyCandidates are encouraged to apply to study courses which fall within AusAID's priority development areas (PDA).

The PDA relate directly to the strategic objectives contained in the Australia and Indonesia Country Strategy. An

indicative list of the areas for study follows.

AustraliaIndonesiaPartnershipPriorityDevelopmentAreas (PDA)

Sustainable Growth andEconomic Management

Democracy Justice andGood Governance

Investing in People Safety and Peace

Description ofPDA

Improving economic policyand management, reducingconstraints to growth ininfrastructure and

productivity, and improvingnatural resourcemanagement, environmentalgovernance and response toclimate change.

Strengthening thecapacity, accountabilityand responsiveness oflegal, democratic andoversight institutions, andimproving localgovernment and publicfinancial management.

Better quality, accessand governance ineducation, and betterhealth access andsystems

Improving responses tohumanitarian needs,emergencies andvulnerability todisasters, andimproving capacity toensure transportsecurity and to counterthreats fromtransnational crime.

AustraliaIndonesiaPartnershipPriority Fieldsof Study

Natural ResourceManagement

Agriculture

Aquaculture/fisheries

Forestry

Climate Change

Economics

Infrastructure Planning

Water and Sanitation Rural Growth

Small and mediumenterprise development

Law, legal andjudicial systems

Political Science andGovernment

Public administration

Public expendituremanagement

Public Sector

Reform Environmental Law

Anti-corruption

Decentralisation

Monitoring &Evaluation

CommunicableDisease Prevention

HealthManagement

Health Services

Maternal and ChildHealth

Women and

Gender Studies Disability Services

Public Health

Education andTraining

EducationManagement

Human ResourceDevelopment

Childhood SpecialEducation

Conflict Resolution

DisasterPrevention andManagement

Transport Safety

TransnationalCrime Prevention

Development

Studies International

Studies

NB: If your study area is not listed here, you may still apply for a field of study related to the work of AusAID in

Indonesia. For more information see the Australia Indonesia Partnership Country Strategy at:

http://www.indo.ausaid.gov.au/docs/aipstrategyinfo.html


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Candidates considering study for particular professions should note that ADS does not include the practical training

period required for professional registration, e.g. medical internships, legal articles etc. Successful awardees are

expected to complete such training in their own country.

Selection ProcessAll applicants are considered by an independent Joint Selection Committee comprised of Australian and Indonesian

academics. Only those shortlisted will be interviewed. The interview will assess candidates' academic ability, clarity of

study goals, cultural adaptability. A critical consideration will be how well the ADS applicant is able to explain the

relevance of their proposed study area to the development of Indonesia. The interview will be accompanied by anIELTS test of English language proficiency.

Final selection is objective and based on the principles of merit and equity. The final list of awardees is subject to

scrutiny and endorsement by AusAID and Government of Indonesia - State Secretariat.

SELECTION QUOTAS:

In the 2011/2012 ADS cycle, up to four hundred (400) ADS scholarships are available for commencement in

2012/2013. The scholarships are allocated as follows:

2/3 of all awards will be offered in the `Public Sector' category

1/3 of all awards will be offered in the `Open' category

up to 50 percent of awards will be offered in the Targeted Sector Category

up to 30 percent of all scholarships will be awarded in line with geographic focus of the Country Program Strategy.

(The geographic focus will include East Nusa Tenggara, West Nusa Tenggara, Papua, West Papua, and

Aceh)

90 percent of awards at Masters level (360) and 10 percent at Doctorate (PhD) level (40). (NB doctoral level

study is only open to staff of universities, higher education institutions, research institute, key policy makers and

targeted candidates in other organizations associated with AusAID activities. Up to eight (8) PhD awards will be

made available to eligible candidates within the Targeted Category

an equal number of awards will be offered to men and women.

NOTIFICATION OF THE SELECTION RESULT

All applicants will be advised whether or not they have been selected for an interview. All interviewed applicants will

be notified whether or not they have been awarded an ADS. The result is final and no correspondence will be entered

into. Where appropriate, notification will include details of pre-departure training (English, academic skills, cultural

preparation). This training is compulsory and full-time (see page 6 for step by step of ADS Application Process).

Requirements for Scholarship RecipientsPrior to travelling to Australia, scholarship recipients must:

meet the minimum English language requirement of their chosen Australian university (usually IELTS of 6.5 with

no band less than 6.0)

at the completion of EAP training, candidates must achieve a minimum score of IELTS 6.0 for ADS office to

commence the application process for placement in a university program in Australia

receive a letter of acceptance from an Australian university

meet Australian immigration requirements for a student visa

receive Government of Indonesia endorsement

be medically fit to commence studies in Australia.


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In Australia, scholarship recipients must:

abide by the conditions of the scholarship and the rules of Australian tertiary institutions

abide by the rules and regulations governing a student visa

act in a way that will not bring disrepute to AusAID, or to any Australian university or to Indonesia

return to Indonesia for a period of two years at the completion of their study/research program in Australia. If

during the two years exclusion period the scholarship recipients return to Australia, a debt to the Commonwealth

may be activated OR any time spent in Australia may be added to the two year exclusion period. Calculation of

the two years exclusion period starts when the scholarships recipients arrive Indonesia, not the visa expire date.

What do Australian Development Scholarships cover? Pre-Course English provision of English for Academic Purposes training prior to commencement of studies in

Australia (including an in-Indonesia stipend)

Tuition Fees - payment of full academic fees and any other fees compulsory for international students.

Introductory Academic Program (IAP) the provision of a 4-6 week Introductory Academic Program prior to the

commencement of studies.

Editorial/tutorial assistance - provided where it is deemed essential to assist awardees to pass course subjects.

Travel - payment of an economy airfare from the principal international airports in Indonesia (Jakarta or Denpasar)

to the major airport nearest the Australian university and return travel to Indonesia. A separate reunion airfare will

be available to the student after the successful completion of the first year of study; subsequent reunion airfare

entitlements will be available on an annual basis for the duration of the ADS, except for the final year of the ADS.

Overseas fieldwork - holders of a scholarship where research comprises at least 50 percent of the program may

receive a return economy class airfare to Indonesia to undertake essential fieldwork.

Contribution to living expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses

(CLE).

Overseas Student Health cover (OSHC) - awardee only (awardees are required to maintain OSHC for any

accompanying family in order to satisfy visa requirements).

Provision of an AusAID Student Visa and Student Dependant visa.

Family EntryAwardees can bring their immediate families to Australia at their own cost, if their families meet AusAID and

immigration requirements. Families are normally permitted to join eight (8) weeks after the awardee's arrival.

Useful websites

Australia Awards: http://australiaawards.gov.au/

Australia Awards Development Scholarships: http://www.ausaid.gov.au/scholar

Australian Development Scholarship (ADS) Indonesia: http://www.adsindonesia.or.id

Visas Department of Immigration and Citizenship: http://www.immi.gov.au

Studying in Australia: http://www.studyinaustralia.gov.au

Australian Educational Institutions and courses - the Commonwealth Register of Institutions andCourses for Overseas Students (CRICOS): http://cricos.deewr.gov.au

IELTS: http://www.ielts.org.au

TOEFL: http://www.ets.org/toefl


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The ADS Application Process

Step 1Applicant sends completeADS application form to

Australia Awards Office by26 August 2011.

Step 2Applicant is notified of

the result of selection forinterview by December 2011.

Step 3Applicant selected for

interview receivesinformation of interview/

IELTS test date/location.

Step 4Applicant attends

interview and IELTS testin January 2012.

Step 5Applicant is advised ofthe result of their ADS

application by February 2012.


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Australian Development Scholarships

2012 Intake Application Form

1. Personal details

Provide supporting documentary evidence of your full name, date of birth, gender and country of

citizenship. For example, the identification page of your passport or other official identification

document issued by your country of citizenship.

* Denotes mandatory field

Attach a recent

passport size photo.

3 x 4 cm.

Title* Mr Mrs Ms Miss Dr

Other(Please specify)

Given name* Enter your family name and other names as shown in yourBirth Certificate, Passport or other official identificationdocument. If you have only one name, enter it in both fields.Family names*

Date of birth* / / dd/mm/yyyy Gender* Male Female

Place of birth*

(State/province)Ethnic group?

Which country are you living in now?*

Have you applied, or are you intending to apply, for permanent

residency or citizenship in Australia or New Zealand?* Yes No

National Identity Number

(KTP No.)

Passport no.

(provide if you have a

passport).*

Issue date / /

Expiry date / /


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2. Contact details

Residential address (Please check that your contact details are correct. The scholarship application takes several months to be finalised. If youcannot be contacted, your application will not proceed.)

Address line 1*

Address line 2

Address line 3

Town/City*

State/Province* Postal code (if any)

Country*

Mailing address (Provide details only if this is different to your current residential address.)

Address line 1

Address line 2

Address line 3

Town/City

State/Province Postal code (if any)

Country

Phone and email (Provide at least one contact number.)

Home phone no.* Work phone no.

Mobile no. Fax no. (if any)

Email 1

Email 2

Current Work address (Please provide your current work address where you can also be contacted. If you cannot be contacted, your applicationwill not proceed.)

Address line 1*

Address line 2

Address line 3

Town/City*


Country*


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3. Spouse details*

If you have dependants (spouse and/or children under 18 years of age), provide their details even if they will not

accompany you to Australia. Note that the scholarship does not provide financial support for accompanying dependants.

You can get information on your responsibilities for your spouse and any dependant children, should they live with you in

Australia during your scholarship, from the Department of Immigration and Citizenship (DIAC) or by contacting the

university where you want to study.

Given name* Provide family name and other names as shown in your spousesbirth certificate, passport or other official identification document*

Family names*

Date of birth* / / dd/mm/yyyy Gender* Male Female

Passport no.

Provide if spouse

has a passport.*

Issue date / /

Expiry Date / /

Country of

citizenship

Will your spouse accompany you to Australia?* Yes No

4. Children details (attach a separate list if there is not enough space)

Provide details of any dependent children and indicate if they will join you in Australia.

A dependent child is the child or stepchild, of yourself or your spouse, who is not married or engaged to be married andhas not turned 18 years of age.

NB: This Scholarship does not provide financial support for family members accompanying you to Australia.

Information on your responsibilities for any children that will live with you in Australia during your scholarship can be

obtained from the Australian Government Department of Immigration and Citizenship website or by contacting the

university where you want to study.

Child 1 Will this child accompany you to Australia?* Yes No

Family name

Given names

Date of birth / / dd/mm/yyyy Gender Male Female

Country of citizenship

Passport no.

Provide if child has a

passport.*

Issue date / /

Expiry date / /


Family name

Given names



Passport no.


passport.*

Issue date / /

Expiry date / /


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Children details continued


Family name

Given names



Passport no.


passport.*

Issue date / /

Expiry date / /

5. Emergency contact details*

Provide details of a person that can be contacted in case of an emergency. This may be a relative or a friend.

Title* Mr Mrs Ms Miss Dr

Other Please specify

Family name*Relationship to

you*

Given name* Gender* Male Female

Home phone* Work phone

Mobile phone Fax (if any)

Email 1

Email 2

Address line 1*

Address line 2

Address line 3

Town/City*


Country* Please check that the contact details are correct

6. Previous scholarships (attach a separate list if there is not enough space)

Only include details of post-secondary school scholarships or fellowships.

Have you previously been awarded a scholarship or a fellowship?* Yes No

1. Scholarship/fellowship title

Start date End date Country

Qualification (if applicable)

University


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Previous scholarships continued

2. Scholarship/fellowship title

Start date End date

Qualification (if applicable)

University

7. Scholarship applications

Have you previously applied for an AusAID scholarship but were

unsuccessful?* Yes No

If "Yes" how many times have you previously applied for ADS?

Have you previously been interviewed by ADS?* Yes No

If Yes, in which years?

8. Disability

Awardees with disabilities are encourage to apply for an ADS. If you do have a disability, the provision of details on

disability will enable appropriate measures to be put in place in the ADS Program.

Do you have a disability or do you work in a disability-focused

organisation? Yes No

If "Yes", please give details and attach any medical assessment if relevant.

9. Under Which Category are you applying for an ADS? *

Open

If Open, please indicate if your application is from:

Private university

Private individual

Public

If Public, please indicate if your application is from:

Government Department

State-owned Enterprise

State University


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Proposed study program* continued

Have you obtained information from the ADS Information CD, or from the ADS

website regarding study options in Australia? Yes No

Please describe the efforts you have undertaken so far to obtain information on your study options in Australia.

ADS - Australian Universities List

Following Australian universities are under contract to AusAID to provide courses for ADS awardees. Awardees are

required to find a suitable course of study at one of these Australian universities. PhD candidates must find a supervisor at

one of these universities. Please visit the following website for more details on Australian Educational Institutions and

courses - CRICOS: http://cricos.deewr.gov.au

Australian Maritime College

Australian Catholic University

Carnegie Mellon University Central Queensland University

Charles Darwin University

Charles Sturt University

Curtin University of Technology

Deakin University

Edith Cowan University

Griffith University

James Cook University

La Trobe University

Macquarie University Monash University

Murdoch University

Queensland University of Technology

RMIT University Southern Cross University

Swinburne University of Technology

The Australian National University

The Flinders University of South Australia

The University of Adelaide

The University of Melbourne

The University of Queensland

The University of Sydney

The University of Western Australia

UCL School of Energy and Resources

University of Ballarat

University of Canberra

University of Newcastle

University of New England University of New South Wales

University of South Australia

University of Southern Queensland

University of Tasmania

University of Technology, Sydney

University of the Sunshine Coast

University of Western Sydney

University of Wollongong

Victoria University

Bond University The University of Notre Dame Australia

Proposed preferences

If you are selected for the scholarship the Australia Awards Office will forward your application to your prefer Australianuniversity and course of study. You need to decide which Australian university you want to attend and choose anappropriate course. You should choose two courses of study. You are encouraged to choose two different Australianuniversities rather than two different courses at the same university. If your application for the first choice of study isunsuccessful, AusAID will forward your application to your second choice. The CRICOS code from your course can befound on the Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS) Websitehttp://cricos.deewr.gov.au

To find out about the content of specific courses, you should refer to the individual Australian university websites. Thisinformation can also be found on the ADS Information CD which can be obtained from the Australia Awards Office or ADSwebsite http://www.adsindonesia.or.id.

Preference 1*

Course title or particular focusarea within your identifiedproposed Field of Study.*

CRICOS code (if applicable)*Australian University(if applicable)

Course duration (weeks)(if applicable)

Minimum Englishlanguage proficiencyrequired for the course(IELTS) (if applicable)


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Proposed preferences continued

Preference 2*

Course title or particular focusarea within your identifiedproposed Field of Study.*

CRICOS code (if applicable)* Australian University(if applicable)

Course duration (weeks)(if applicable)

Minimum Englishlanguage proficiencyrequired for the course(IELTS) (if applicable)

A formal offer of admission will not be required however it is expected serious

PhD candidates will have made preliminary enquiries to possible Australian

universities regarding their study.

Have you discussed your proposed course with a member of staff from any

Australian university? This is highly recommended for PhD applicants. If Yes,

please attach any relevant correspondence with Australian universities.

Yes No

Are there any special subjects or skills development that you would like to include

in your choice?Yes No

If "Yes" please give details. (Note that ADS does not include the practical training period required for professional

registration, e.g. medical internship, legal articles etc. Applicants are expected to complete such practical training in their

own country).


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Research proposal details

Complete this section if the studies will be by Research or a combination ofResearch and Coursework. E.g. Doctorateor Masters by Research. Otherwise proceed to next question. Answers should be concise but sufficient to explain thenature of your research proposal to the selection panel. Please note word limits. Anything over this limit will not beconsidered.

Research title

(max 250 characters,approx 30-50 words limit)

What is the background to

the research being

proposed? (maximum 150

words / + 1,000

characters)

Provide a Research

Statement (purpose of

study) to accompany the

proposed research. This

can include a statement on

what is special and unique

about the research?)

(maximum 100 words / +

700 characters)

What hypothesis are you

testing in your proposed

research? (maximum 50

words / + 350 characters)

What are the objectives of

the proposed research?

(maximum 200 words / +

1,300 characters)


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Research proposal details

What is the

methodology/structure in

your proposed research?

(include comments on

measurements, data

sources, methods of

analysis and timelines)(maximum 200 words / +

1,300 characters)

Have you published any

research to date? (include

texts, journal articles

providing full citation)

Which university do you

consider appropriate for

your proposed studies?Why? (maximum 50 words /

+ 350 characters)

Have you considered a

possible research

supervisor? Why this

selection?(maximum 50

words / + 350 characters)

What is the relevance of

the proposed research to

Indonesia?

Does your proposed research include fieldwork?* Yes No Not sure

If `Yes please provide a description of the fieldwork you will be undertaking. (Max 1000 characters, approx 200 words

limit).

What is the duration of your proposed fieldwork? (if known) Weeks

In which country will you undertake the proposed fieldwork?

Proposed fieldwork supervisor (if known)


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11. Qualifications*

List qualifications (whether complete or not) by level of study, starting with the highest. If you have not completed

your studies please list your anticipated end date. Applicants are required to fill out the total GPA obtained and the

maximum GPA possible for each qualification noted below.

Three certified copies of official transcripts and certificates MUST be included with this application. If you are selected for

interview, you MUST provide certified English translations when you attend the interview.

1. Qualification name*

Level of study*

Secondary (High School) Vocational, Technical( DIII or DIV )

Undergraduate (S1) Postgraduate (S2 or S3 )

Name of university*

State/Province Country*

Language of instruction* Start date * / /

GPA (if applicable) Obtained / Max End date* / /

Status Complete Pending results Incomplete

2. Qualification name*

Level of study*



Name of university*

State/Province Country*

Language of instruction* Start date* / /

GPA (if applicable) Obtained / Max End date* / /


3. Qualification name

Level of study



Name of university

State/Province Country

Language of instruction Start date / /

GPA (if applicable) Obtained / Max End date / /



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12. English language proficiency*

Applicant must have an English language proficiency of at least 5.0 in IELTS (or 500 in paper-based TOEFL or 39 in

internet-based TOEFL). The IELTS or TOEFL (Institutional or International) result must be current (a test result obtained in

2010 or 2011 will be considered current). An original copy of your IELTS or TOEFL certificate must be attached to the

application form. NO other English language test (including TOEFL prediction) result will be accepted.

Is English your first language? Yes No

If `Yes go to next section. If `No answer the following questions:

Was English the language of your highest level of study? Yes No

If `Yes, provide a statement from the universityverifying the language of instruction.

Have you taken an IELTS or TOEFL test? Yes No

Test name (e.g.

IELTS or TOEFL)

Date test

taken/ / Overall

score

Test Centre/location Phone Website

If `No, when do you expect to complete the

test?/ / Test name

13. Computer literacy*

Please answer the following questions to the best of your ability. This will assist Australian universities to decide whether

to provide additional tuition.

Are you computer literate?* Yes No

How regularly do you use a PC?* Occasionally Daily Weekly Monthly

Do you have experience with the following software?*

Word processing software

(e.g. Word)? Yes No

Spreadsheet software (e.g.

Excel)? Yes No

Database software (e.g.

Access)? Yes No

Operating systems (e.g.

Windows 2000)? Yes No

Presentation software (e.g.

PowerPoint)? Yes No

Email software (e.g.

Outlook)? Yes No

Internet browsers (e.g.

Internet Explorer)? Yes No

Statistical packages (e.g.

SPSS or Minitab)? Yes No

14. Computer training details

List any formal computer courses you have undertaken.

Course name 1

Start date / / End date / /

Course name 2



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15. Current employment

Current employment may include work experience and voluntary work. Please enter Not Applicable in the Position

Title if you are not currently employed. You must provide a current CV.

Position title*

Organisation*

Level of position in

organisation structure

(eg. Echelon and Golongan)

Date commenced* / /

Sector/organisation type Government/Public NGO /Civil Society Private

Briefly describe the work of

your organisation and the

service it provides.

Briefly describe your current

duties and responsibilities

(max 500 characters, approx

80-100 words limit)

Do you intend to return to this organisation after your scholarship in Australia?* Yes No

If Yes, what role andresponsibilities do you

expect to undertake after

your academic studies?


80-100 words limit)

What specific tasks do you

anticipate being able to

undertake after youracademic studies? (specify

at least 3) (max 500

characters, approx 80-100

words limit)


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16. Previous relevant employment

Only provide previous employment that is relevant o your application. Employment history should also include workexperience, community work and voluntary work.

1. Previous position

Position title

Organisation


Duties/responsibilities


80-100 words limit)

2. Previous position

Position title


Organisation

Duties/responsibilities

(max 500 characters,

approx 100 words limit)

17. Interview Centre *

Please tick your preferred interview center. (Please note Your choice is not guaranteed.)

Jakarta

Yogyakarta

Surabaya

Denpasar

Medan

Padang

Balikpapan/Banjarmasin

Jayapura

Makassar

Manado

Kupang


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18. Supporting statement

Limit your answers to 500 characters, approx 80-100 words, per question. Attach a page if not enough room on this form.Please note word limits. Anything over this limit will not be considered.

1. Why do you want to study in Australia?*

2. What skills and knowledge do you hope to gain and how do you propose to use them?*

3. How will the proposed training be of benefit to Indonesia?*


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Supporting statement continued

4. Do you currently have any connection or relationship to any staff employed at

AusAID Posts or with AusAIDs managing contractors?* Yes No

If `Yes please expand.

5. Are you subject to any criminal or civil proceedings that are currently awaiting

legal action?* Yes No

If `Yes please expand. Please note information provided here will not necessarily disqualify you from submitting this scholarship application.

6. Is there anything else you would like to add? (E.g. Will you require special assistance or equipment to

participate in the Scholarship selection processes or to live and undertake studies in Australia?)


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19. Professional memberships

Professional memberships may include community, cultural, political, scientific, professional and/or educational

associations and organisations.

1. Organisation Name

Highest position held (if any)







Start date/ /


20. Communication*

Where did you first learn of the Australian Development Scholarships?(tick box and specify where asked to do so)

AusAID scholarship recipient Australia Awards websiteAusAID or Managing

Contractors Office

Friend, relative or colleague AusAID Website Home institution or university

Australian Embassy or

Australian Education Centre(specify location)

Australian institution or

university(specify)

Publication, Radio, TV

(specify)

Workplace or nominating authority

(specify)

Other

(specify)

From where did you obtain your application form? (tick box and specify where asked to do so)

ADS website ADS Office AusAID Office

Friend, relative or colleague DEEWR Office GoI State Secretariat Office

Education Agent (specify)Home institution or university

(specify)

AusAID project office

(specify)

Workplace or nominating authority

(specify)

Other

(specify)


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21. Checklist of documentary evidence*

Please note: You are responsible for providing all supporting documents are provided. If you do not provide all required

documents your application will be rejected.

THREE COPIES of the completed application form. At least one copy of the application form should have certified* copies attached of the relevant documents

listed below. Where original documents are not in English, you must provide certified* copies of official English translations

if you are selected for an interview.

* Certified: a statement that the document is a true copy, signed by a Commissioner of Oaths, Public Notaryor otherformally recognised authority. If you are unsure about who is the appropriate person to certify your documents, youshould contact the ADS Office.

Required documentation: please tick if you have attached the following documents in support of your application.

All applicants: (Essential)

You MUST include all the essential documents. If at least one essential document is not provided, your application will be

automatically rejected.

copies of birth certificate or equivalent Yes N/A

proof citizenship i.e. KTP or your passport personal information pages Yes N/A

current Curriculum Vitae Yes N/A

official (certified* ) post-secondary and tertiary certificates/degrees Yes N/A

official (certified* ) post-secondary and tertiary transcripts of results Yes N/A

current (original) IELTS orTOEFL English language test results (a test result obtained

in 2010 or 2011 will be considered current). TOEFL prediction test is NOTaccepted.

Yes N/A

Masters applicants must also attach certified DIII degree certificate/transcript if using

DIV or S1 extension certificate/transcriptYes N/A

Doctorate applicants must also attach certified S1 degree certificate/transcript Yes N/A

academic reference from S2 supervisor for Doctorate candidates Yes N/A

Doctorate and those Masters applicants whose study will include at least fifty percent

research must fill the research proposal details on page 15 of this application formYes N/A

Additional Documents: (Optional)

Applicants must provide the following documents if they are selected for an interview.

recent photograph (3 x 4) Yes N/A

official (certified* ) English translations of post-secondary and tertiary

certificates/degreesYes N/A

official (certified* ) English translations of post-secondary and tertiary transcripts of

resultsYes N/A

references from S1 supervisor for Masters candidates (if available) Yes N/A

list of relevant publications, unpublished theses (for research applicants) Yes N/A

statement from university that English is a language of instruction (if applicable) Yes N/A

relevant correspondence with an Australian university (if available). Yes N/A

official (certified*) English translations of birth certificate Yes N/A

IMPORTANT:

Attach only certified copies of documents. DO NOT attach original documents.

Application forms and documents will not be returned.


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22. Conditions of Scholarships

WARNING:

In section 22, 23 and 24 you will be agreeing to important conditions attached to your award and your study in Australia.Failure to comply with these conditions will mean that you may incur a debt to the Government of Australia and yourscholarship may be terminated.

DO NOT sign the declaration at the end of section 23 and 24 until you fully understand the conditions of the scholarshipaward. If you have any problems understanding Section 22, 23 and 24 you are strongly advised to seek clarification of

these conditions from the Australia Awards Office.

If you are offered a scholarship you will be asked to agree to certain conditions before accepting the scholarship. The mainconditions are set out below for your information.

In accepting an Australian Development Scholarship, you will be asked to:

take up the ADS in the academic year for which it is offered;

complete a full study program during the course of their scholarship;

not hold another Australian Government scholarship at the same time as the ADS;

participate in the Pre-Departure Briefing arranged by the Post, and the universitys compulsory IntroductoryAcademic Program (IAP) on arrival in Australia;

reside in Australia for the duration of the ADS (apart f rom holidays, reunion visits or fieldwork visits to their home

country); complete their ADS award within the period stipulated in their Student Contract;

only undertake the approved program for which the ADS is offered and abide by the rules of the university;

maintain an appropriate study load and achieve satisfactory academic progress in the program for which theADS was offered;

participate in all activities associated with the approved course of study, including all lectures and tutorials,submit all work required for the course (e.g. assignments or essays) and sit fo r examinations;

not undertake any additional off-scholarship tertiary studies during their time in Australia on an AusAID StudentVisa;

be aware that any employment undertaken during term times may compromise academic progress;

liaise with the Student Contact Officer at the university regarding any proposed changes to the approvedprogram and acknowledge that approval is required from the university, AusAID and Partner Government beforeany changes are made;

agree to AusAID collecting information concerning the Student or dependants and passing that information on toother relevant parties, if necessary;

advise AusAID immediately, via the Student Contact Officer at the university, if they marry a person who is anAustralian or New Zealand citizen, or who has permanent residence status in Australia or New Zealand. Thechange in a students marital status may affect eligibility to maintain the ADS Scholarship, and the Debt to theCommonwealth may apply if the student does not return to their home country for a period of 2 years;

return to their country of citizenship for two years at the completion of their study/research program in Australia;.

be aware that a Debt to the Commonwealth of Australia will be incurred if a Student fails to return to their homecountry, or if they apply for Permanent Residence or for a visa to remain in or return to Australia within the two

year period; and that any time spent in Australia during the two year return home period will accordingly extend the end date of

the two year period;

agree that their ADS may be terminated at any time for failure to make satisfactory academic progress, failure tocomply with the laws of Australia, misconduct, breaches of the contract between the Student and theCommonwealth of Australia including breaches of the conditions of the ADS or of the AusAID Student Visa or ifthey apply to change their visa status.


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23. Nominating Agency Declaration - required for Public sector applicants only*

(NB: to be completed by the staff member within your organisation authorised to release staff for overseas study - forexample staff from the International Relations Bureau (BKLN) / Centre for Education and Training / the Planning Bureau /Rector from the university as appropriate. Applicants from outside Jakarta must have the approval and nomination of theirrelevant Kakanwil or Kadinas.)

Please note that your signature on this form signifies your agreement to the following:

to release the applicant from work duties while he/she attends English for academic training. This training is full-

time and compulsory

to release the applicant from work duties after English for academic training to study in Australia, and processtheir official passport and exit permit

to cover the cost of travel to and from English for Academic Purposes training (Bali/Jakarta)

to cover the cost of travel to the point of departure (Bali/Jakarta) prior to travel to Australia to cover the cost ofmedical examinations for the applicant. A medical examination is an Australian Immigration requirement toreceive a student visa

to select a field of study and level of study appropriate to the agency's needs.

Please also note that if the application is for Doctorate level study, the signature by the authorised staff member confirmsthat the applicant is a lecturer/researcher/key planner or policy maker and that Doctorate level studies are essential forhis/her future research and /or teaching responsibilities.

Name of Ministry/Employer

Name of Applicant

Applicants Position title

Applicants Level of position

in organisation structure

(eg. Echelon and Golongan)

Date commenced / /

How long have you known the applicant and

in what capacity?

Please make any additional comments about

the applicant's potential or personal qualities

which you feel would be helpful to the ADS

Selection Team.

Ministry/Agency Representative signature*

On behalf of the ministry, I the undersigned, agree to be bound to the above commitments and st rategies

Full Name Signature & stamp

Position

Email

Mobile

Date / /


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24. Applicants authorisation, agreement, declaration and signature*

Authorisation

AusAID must comply with the Privacy Act 1988in relation to the personal information you have provided in this form.

By submitting this form I authorise AusAID, or its appointed managing contractor, to access and/or obtain information,including copies of any of my relevant academic records/reports from the Australian University(s) that I have attended forthe following purposes:

for use in the selection process for an Australia Award to monitor my academic performance at my host university while studying under an Australian Development

Scholarships

to brief relevant Australian officials, Ministers and members of Parliament.

Should I receive an Australia Award, I consent to the Australian Government using and disclosing extracts of myapplication (relating to my academic background and achievements, leadership skills and my proposed study program in

Australia) in promotional material in hardcopy and on the Internet. I note that promotional material may include, but is notlimited to, media releases and information circulated to AusAIDs offshore Posts and Australian universities, concerningthe Australian Development Scholarships.

I authorise AusAID to disclose the personal information collected in this form to other Australian Government departmentsfor the purpose of promoting and managing the Australian Development Scholarship.

Understanding

I understand and confirm that:

I have read and complied with the Scholarships Handbook and that the contents of my application are true andcorrect

AusAID has the right to vary or reverse any decision regarding an Australia Development Scholarships made onthe basis of incorrect or incomplete information

Decisions of the selection panel are final and confidential and no correspondence about outcomes of theselection process will be entered into.

Agreement

If successful in gaining an Australia Development Scholarships, I agree that I wil l:

undergo a police or character check before my Australia Development Scholarships is confirmed

immediately provide AusAID with details of any incident that may ref lect badly on the prestige of an AustraliaDevelopment Scholarships

act in a manner befitting a recipient of an Australia Development Scholarships

use the funds for the purposes granted

acknowledge the assistance given by the Australian Government in any written reports, publications or publicityassociated with the Scholarships.

Declaration and acknowledgement

I declare, in submitting this application form, that the information contained in it and provided in connection with it is trueand correct.

I acknowledge that giving false or misleading information is a serious offence under the Criminal Code Act 1995

of the Commonwealth of Australia.

Full Name Signature Date

/ /


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25. Ministry of State Secretariat of the Republic of Indonesia use only

Endorsement by the Government of Indonesia

( To be completed by Head, Bureau of Technical Cooperation, Ministry of State Secretariat of the Republic of Indonesia )

On behalf of the Government of Indonesia, I certify that I have examined the documents attached to this form and am

satisfied that they are authentic and relate to the applicant.

I certify that the maximum level of study, field of study and length of award proposed in this application are appropriate

and in accordance with the Government's training policy.

I endorse the applicant for an Australian Development Scholarship.

Name of certifying officer

Title

Organisation

Official Stamp Signature Date

/ /

8011-ADS 2012 Intake Application Form

Documents

Transcript of 8011-ADS 2012 Intake Application Form