Ads Applicationform 2011

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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 of all 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 SecretariatoftheRepublic 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 orcentral 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 to

the ADS Program independently of their employer.

`Targeted Category' candidates are employed by organisations which are identified by the Government of Indonesiaand 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 TOEFLprediction 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 Study

Candidates 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, and improvingcapacity to ensuretransport security and tocounter threats 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

Health Management Health Services

Maternal and ChildHealth

Women and GenderStudies

Disability Services

Public Health

Education andTraining

EducationManagement

Human ResourceDevelopment

Childhood SpecialEducation

Conflict Resolution

Disaster Prevention

and Management Transport Safety

Transnational

Crime Prevention

DevelopmentStudies

InternationalStudies

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 Process

All 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 therelevance of their proposed study area to the development of Indonesia. The interview will be accompanied by an

IELTS 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 Recipients

Prior 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 Scholarshipscover?

> 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 thecommencement 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 Entry

Awardees 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

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

The ADS Application Process

6

Step 1Applicant sends

completeADS application form toAustralia Awards Office

by26 August 2011.

Step 2Applicant is notified ofthe result of selection

forinterview by December

2011.

Step 3

Applicant selected forinterview receivesinformation of

interview/IELTS test date/location.

Step 4

Applicant attendsinterview and IELTS testinJanuary 2012.

Step 5Applicant is advised ofthe result of their ADS

application byFebruary 2012.


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Australian Development Scholarships2012 Intake Application Form

1. Personal details

Provide supporting documentary evidence of your full name, date ofbirth, gender and country of citizenship. For example, the identificationpage of your passport or other official identification document issued byyour country of citizenship.

* Denotes mandatory field

Attach a recentpassport size

photo.

3 x 4 cm.

Title* Mr Mrs Ms Miss DrOther(Please specify)

Given name* LARAP KEMAYAN ESTU Enter your family name and other names asshown in your Birth Certificate, Passport orother official identification document. If youhave only one name, enter it in both fields.Family names* LARAP KEMAYAN ESTU

Date of birth* 29/ 10/ 1986 dd/mm/yyyy Gender* Male

Place of birth*(State/province) EAST JAVA Ethnicgroup? JAVANESE

Which country are you living in now?* INDONESIA

Have you applied, or are you intending to apply, forpermanent residency or citizenship in Australia orNew Zealand?*

Yes No

National IdentityNumber

Passport no.(provide if you havea passport).*

Issue date / /

Expiry date / /

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2. Contact details

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

Address line 1* Jl. Kalimantan no 9

Address line 2 Address line 3 Town/City* Mojokerto

State/Province* East Java Postal code (if 61321

Country* Indonesia

Mailing address (Provide details only if this is different to your current residentialAddress line 1 jl. Tanah Kusir II no 18

Address line 2 RT 08/ RW 09

Address line 3 Town/City Jakarta Selatan

State/Province Jakarta Postal code (if 12240

Country Indonesia

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

Home phone no.* +6285646433435 Work phone +622172797189

Mobile no. +6285646433435 Fax no. (if +622172797189

Email 1 [email protected]

Email 2 Current Work address (Please provide your current work address where you can also be contacted. Ifyou cannot be contacted, your application will not proceed.)

Address line 1* Subdit. Drainase DJCK, Kementerian PU

Address line 2 jl. Pattimura no 20, Gd. Menteri lt. 7

Address line 3 Town/City* Jakarta SelatanState/Province* DKI Jakarta Postal code (if 12110

Country* Indonesia

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3. Spouse details*

If you have dependants (spouse and/or children under 18 years of age), provide theirdetails even if they will not accompany you to Australia. Note that the scholarship doesnot provide financial support for accompanying dependants. You can get information onyour responsibilities for your spouse and any dependant children, should they live withou in Australia durin our scholarshi , from the De artment of Immi ration and

Given name* Provide family name and other names as shown inyour spouses birth certificate, passport or otherofficial identification document*Family

Date of birth* / / dd/mm/yyyy Gende Male FemalePassport no.Provide if

Issue date / / Expiry Date / /

Country ofcitizenship

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 marriedor engaged to be married and has not turned 18 years of age.

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

Information on your responsibilities for any children that will live with you in Australiaduring your scholarship can be obtained from the Australian Government Department of

Child 1 Will this child accompany you to Australia?* Yes NoFamily name Given names Date of birth / / dd/mm/yyyy Gender Male FemaleCountry of

Passport no.Provide if child has

Issue date / / Expiry date / /

Child 2 Will this child accompany you to Australia?* Yes No

Family name Given names Date of birth / / dd/mm/yyyy Gende Male FemaleCountry of



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Children details continued

Child 3 Will this child accompany you to Australia?* Yes

Family name Given names Date of birth / / dd/mm/yyyy Gende Male FemaleCountry of



5. Emergency contact details*

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

Title* Mr Mrs Ms Miss Dr

Other Please

Family name*Amelynda OktaviyanaSuzzan

Relationshipto you*

Girl Friend

Given name* Amelynda Oktaviyana Gender* Male Female

Home phone* +628563580570 Work phone +622130403029

Mobile phone +628563580570 Fax (if any) Email 1 [email protected]

Email 2 Address line 1* jl. Setiabudi II no 16

Address line 2 Address line 3 Town/City* Jakarta Selatan

State/Province* DKI Jakarta Postal code (if 12910

Country* Indonesia Please check that the contact details

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 Yes No

1.

Start date End date Country Qualification (if

University

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Previous scholarships continued

2.

Start date End date Qualification (if

University 7. Scholarship applications

Have you previously applied for an AusAIDscholarship 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 inthe ADS Program.

Do you have a disability or do you work in adisability-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 applicationis from:

Private university

Private individual

Public

If Public, please indicate if yourapplication is from:

Government Department

State-owned Enterprise

State University

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10. Proposed study program*

AusAID will consider offering you a scholarship only if your course of study will contributeto the long-term development needs of your country. Note that the proposed program ofstudy should be appropriate to your academic qualification and work experience.

Requested Level of

study* (You will not beallowed to upgrade yourcourse from the level atwhich you are first

Masters

Doctorate(PhD)

Type of study*(Masters

coursework program cancontain a research projectup to 30% of the Masters.Candidate decide the topicdurin course

Coursework Research

Combination

Research background of Doctorate(PhD) candidates only:*

Do you hold a Masters degree with > 50% weighting for research? Yes No

Are you including a letter from your Masters supervisor recommending that youshould pursue Doctorate studies? (Recommended) Yes No

Proposed field of study*

You are required to:

Identify the priority Development Area (PDA) for your proposed studies. (Pleasetick one box only).

Identif the Priorit Field of Stud (PFS) from the list of referred PFS rovided

AustraliaIndonesiaPartnershipPriority

SustainableGrowth andEconomicManagement

DemocracyJustice andGoodGovernance

Investing inPeople

Safety and Peace

Description ofPDA

Improvingeconomic policyand management,

reducingconstraints togrowth ininfrastructure and

productivity, andimproving naturalresource

Strengthening thecapacity,accountability and

responsiveness oflegal, democraticand oversightinstitutions, andimproving localgovernment and

public financial

Better quality,access andgovernance in

education, andbetter healthaccess andsystems

Improving responsesto humanitarianneeds, emergencies

and vulnerability todisasters, andimproving capacity toensure transportsecurity and tocounter threats fromtransnational crime.

AustraliaIndonesiaPartnershipPriority

Fields ofStudy(PFS)*

NaturalResourceManagement

Agriculture

Aquaculture/fisheries

Forestry

Climate Change

Economics

InfrastructurePlanning

Water andSanitation

Rural Growth

Small and

Law, legal andjudicial systems

Political ScienceandGovernment

Publicadministration

Publicexpendituremanagement

Public SectorReform

EnvironmentalLaw

Anti-corruption

Decentralisatio

CommunicableDiseasePrevention

HealthManagement

Health ServicesMaternal andChild Health

Women andGender Studies

DisabilityServices

Public Health

Education andTraining

EducationManagement

Human

Conflict Resolution

DisasterPrevention andManagement

Transport Safety

TransnationalCrime Prevention

DevelopmentStudies

InternationalStudies

Other,please specify:

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Proposed study program* continued

Have you obtained information from the ADS InformationCD, or from the ADS website regarding study options inAustralia?

Yes No

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

ADS - Australian Universities List

Following Australian universities are under contract to AusAID to provide courses for ADSawardees. Awardees arerequired to find a suitable course of study at one of these Australian universities. PhDcandidates must find a supervisor at one of these universities. Please visit the followingwebsite for more details on Australian Educational Institutions and courses - CRICOS:http://cricos.deewr.gov.au

Australian MaritimeCollege

Australian CatholicUniversity Carnegie MellonUniversity

Central QueenslandUniversity

Charles Darwin University

Charles Sturt University

Curtin University ofTechnology Deakin University

Edith Cowan University

Griffith University James Cook University La Trobe University Macquarie University Monash University

Murdoch University Queensland University ofTechnology RMIT University Southern Cross University Swinburne University ofTechnology The Australian NationalUniversity 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 andResources University of Ballarat

University of Canberra University of Newcastle University of NewEngland University of New SouthWales University of South

Australia University of SouthernQueensland

University of Tasmania University of Technology,Sydney University of theSunshine Coast University of WesternSydney University of Wollongong Victoria University Bond University The University of NotreDame Australia

Proposed preferences

If you are selected for the scholarship the Australia Awards Office will forward yourapplication to your prefer Australian university and course of study. You need to decidewhich Australian university you want to attend and choose an appropriate course. Youshould choose two courses of study. You are encouraged to choose two differentAustralian universities rather than two different courses at the same university. If yourapplication for the first choice of study is unsuccessful, AusAID will forward yourapplication to your second choice. The CRICOS code from your course can be found onthe 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 individualAustralian university websites. This information can also be found on the ADS InformationCD which can be obtained from the Australia Awards Office or ADS websitehttp://www.adsindonesia.or.id.

Preference 1* Civil Engineering, n.f.d

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Course title orparticular focus areawithin your identified

CRICOS code (ifapplicable)*

060721CAustralianUniversity

The University ofWestern Australia (UWA)

Course duration

(weeks)(if applicable)

104

Minimum Englishlanguage

proficiencyrequired for the

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Proposed preferences continued

Preference 2*

Course title orparticular focus areawithin your identifiedproposed Field of

CRICOS code (ifapplicable)*

AustralianUniversity(if applicable)

Course duration(weeks)(if applicable)

Minimum Englishlanguageproficiencyrequired for the

A formal offer of admission will not be required however itis expected serious PhD candidates will have made

preliminary enquiries to possible Australian universitiesregarding their study.

Have you discussed your proposed course with a memberof staff from any Australian university? This is highly

Yes No

Are there any special subjects or skills development thatyou would like to include in your choice?

Yes No

If "Yes" please give details. (Note that ADS does not include the practical training periodrequired for professional registration, e.g. medical internship, legal articles etc. Applicantsare 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 ofResearchand Coursework. E.g. Doctorate or Masters by Research. Otherwise proceed to nextquestion. Answers should be concise but sufficient to explain the nature of yourresearch proposal to the selection panel. Please note word limits. Anything over

Research title(max 250characters, approx30-50 words limit)

Stability of Water Pump for Drainage function

What is thebackground to theresearch beingproposed?(maximum 150words / + 1,000characters)

Kurang efektinya sistem drainase di Indonesia sehingga menuntutengineer untuk mampu membuat bangunan "drainage pumping" ygmemiliki stabilitas yang mencukupi untuk kondisi yang kuarngmemadai di Indonesia.

Provide a ResearchStatement (purposeof study) toaccompany theproposed research.This can include astatement on whatis special andunique about the

research?)(maximum 100words / + 700characters)

Memberi kontribusi pada negara

What hypothesis areyou testing in yourproposed research?(maximum 50words / + 350characters)

What are the

objectives of theproposed research?(maximum 200words / + 1,300characters)

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Research proposal details

What is themethodology/structure in yourproposed research?(include comments

on measurements,data sources,methods of analysisand timelines)(maximum 200words / + 1,300characters)

Have you publishedany research todate? (include texts,journal articles providing full

citation)

Which university doyou considerappropriate for yourproposed studies?Why? (maximum 50words / + 350characters)

Have youconsidered apossible researchsupervisor? Why

this selection?(maximum 50words / + 350characters)

What is therelevance of theproposed researchto Indonesia?

Does your proposed research include Yes No Not sure

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

What is the duration of your proposed fieldwork? Weeks

In which country will you undertake the proposed

Proposed fieldwork supervisor (if known)

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11. Qualifications*

List qualifications (whether complete or not) by level of study, starting with thehighest. 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 possiblefor each qualification noted below.Three certified copies of official transcripts and certificates MUST be included with this

1. Qualification Bachelor's Degree of Civil Engineering

Level of study*

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

Under raduate S1 Post raduate S2 or

Name of university* Brawijaya University

State/Province East Java Country* Indonesia

Language of instruction* Bahasa Indonesia Start date * 19/ 7/ 2004

GPA (if applicable) Obtained / Max End date* 12/ 2/ 2009

Status Complete Pending results Incomplete

2. Qualification

Level of study*


Under raduate (S1) Post raduate (S2 or

Name of university* State/Province Country* Language of instruction* Start date* / / GPA (if applicable)

Obtained / MaxEnd date* / /

Status Complete Pending results Incomplete

3. Qualification name

Level of study


Under raduate (S1) Post raduate (S2 or

Name of university

State/Province Country Language of instruction Start date / / GPA (if applicable) Obtained / Max End date / / Status Complete Pending results Incomplete

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12. English language proficiency*

Applicant must have an English language proficiency of at least 5.0 in IELTS (or 500 inpaper-based TOEFL or 39 in internet-based TOEFL). The IELTS or TOEFL (Institutional orInternational) result must be current (a test result obtained in 2010 or 2011 will beconsidered current). An original copy of your IELTS or TOEFL certificate must be attached

Is English your first language? Yes NoIf `Yes go to next section. If `No answer the following questions:

Was English the language of your highest Yes No

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

Have you taken an IELTS or TOEFL Yes No

Test name(e.g. IELTS or TOEFL

Datetest

/ / Overallscore

573

TestCentre/location

AMINEF/Jakarta Phone Website If `No, when do you expect tocomplete the test?

/ / Testname

13. Computer literacy*

Please answer the following questions to the best of your ability. This will assistAustralian universities to decide whether to provide additional tuition.

Are you computer literate?* Yes No

How regularly do you usea PC?*

Occasionally Daily Weekly

Monthly

Do you have experience with the following software?*

Word processingsoftware (e.g.Word)?

Yes NoSpreadsheetsoftware (e.g.Excel)?

Yes No

Database software(e.g. Access)?

Yes NoOperating systems(e.g. Windows2000)?

Yes No

Presentationsoftware (e.g.PowerPoint)?

Yes NoEmail software (e.g.Outlook)?

Yes No

Internet browsers(e.g. InternetExplorer)?

Yes NoStatistical packages(e.g. SPSS orMinitab)?

Yes No

14. Computer training details

List any formal computer courses you have undertaken.

Course name 1 Start date / / End date / / Course name 2

Start date / / End date / /

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15. Current employment

Current employment may include work experience and voluntary work. Please enterNot Applicable in the Position Title if you are not currently employed. You must

Position title* Organisation* Level of position inorganisationstructure(eg. Echelon andGolongan)

Datecommenced*

/ /

Sector/organisation Government/Public NGO /Civil Society

Briefly describe thework of yourorganisation and theservice it provides.

Briefly describe yourcurrent duties andresponsibilities(max 500 characters,approx 80-100 wordslimit)

Do you intend to return to this organisation after your Yes

If Yes, what roleand responsibilitiesdo you expect toundertake after youracademic studies?(max 500characters, approx80-100 words limit)

What specific tasksdo you anticipatebeing able toundertake after youracademic studies?(specify at least 3)(max 500characters, approx80-100 words limit)

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16. Previous relevant employment

Only provide previous employment that is relevant to your application. Employmenthistory should also include work experience, community work and voluntary work.

1. Previous position

Position title

Organisation Start date / / End date / / Duties/responsibilities(max 500characters, approx80-100 words limit)

2. Previous position

Position title Start date / / End date / / Organisation Duties/responsibiliti

es(max 500characters, approx100 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 pageif not enough room on this form. Please note word limits. Anything over this limit

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

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 relationshipto any staff employed at AusAID Posts or with AusAIDsmanaging contractors?*

Yes No

If `Yes please expand.

5. Are you subject to any criminal or civil proceedingsthat 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 specialassistance or e ui ment to artici ate in the Scholarshi selection rocesses

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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

Start date / / End date / / 2. Organisation Name Highest position held (if

Start date / / End date / / 3. Organisation Name Highest position held (if

Start date / / Start date / / End date / /

20. Communication*

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

AusAID scholarshiprecipient

Australia Awardswebsite

AusAID or ManagingContractors Office

Friend, relative orcolleague

AusAID WebsiteHome institution oruniversity

Australian Embassy orAustralian EducationCentre (specify location)

Australian institutionor university(specify)

Publication, Radio, TV

(specify)

Workplace or nominatingauthority (specify)

Other(specify)

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

ADS website ADS Office AusAID Office

Friend, relative orcolleague

DEEWR OfficeGoI State SecretariatOffice

Education Agent(specify)

Home institution oruniversity (specify)

AusAID project office(specify)

Workplace or nominatingauthority (specify)

Other(specify)

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21. Checklist of documentary evidence*

Please note: You are responsible for providing all supporting documents are provided. Ifyou 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* copiesattached 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 Commissionerof Oaths, Public Notaryor otherformally recognised authority. If you are unsureabout who is the appropriate person to certify your documents, you should contact theADS Office.

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

All applicants: (Essential)

You MUST include all the essential documents. If at least one essential document is notprovided, your application will be automatically rejected.

copies of birth certificate or equivalent Yes N/A

proof citizenship i.e. KTP or your passport personal informationpages

Yes N/A

current Curriculum Vitae Yes N/A

official (certified* ) post-secondary and tertiarycertificates/degrees

Yes N/A

official (certified* ) post-secondary and tertiary transcripts ofresults

Yes N/A

current (original) IELTS or TOEFL English language test results

(a test result obtained in 2010 or 2011 will be consideredcurrent). TOEFL prediction test is NOT accepted. Yes N/A

Masters applicants must also attach certified DIII degreecertificate/transcript if using DIV or S1 extensioncertificate/transcript

Yes N/A

Doctorate applicants must also attach certified S1 degreecertificate/transcript

Yes N/A

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

Doctorate and those Masters applicants whose study will includeat least fifty percent research must fill the research proposaldetails on page 15 of this application form

Yes 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-secondaryand tertiary certificates/degrees

Yes N/A

official (certified* ) English translations of post-secondaryand tertiary transcripts of results

Yes N/A

references from S1 supervisor for Masters candidates (ifavailable)

Yes N/A

list of relevant publications, unpublished theses (for researchapplicants)

Yes N/A

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

relevant correspondence with an Australian university (ifavailable).

Yes N/A

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

IMPORTANT:

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

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 youraward and your study in Australia. Failure to comply with these conditions will mean thatyou may incur a debt to the Government of Australia and your scholarship may beterminated.

DO NOT sign the declaration at the end of section 23 and 24 until you fully understandthe conditions of the scholarship award. If you have any problems understanding Section22, 23 and 24 you are strongly advised to seek clarification of these conditions from theAustralia Awards Office.

If you are offered a scholarship you will be asked to agree to certain conditions beforeaccepting the scholarship. The main conditions 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 universityscompulsory Introductory Academic Program (IAP) on arrival in Australia;

reside in Australia for the duration of the ADS (apart from holidays, reunion visitsor 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 bythe rules of the university;

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

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

not undertake any additional off-scholarship tertiary studies during their time inAustralia on an AusAID Student Visa;

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

liaise with the Student Contact Officer at the university regarding any proposedchanges to the approved program and acknowledge that approval is required fromthe university, AusAID and Partner Government before any changes are made;

agree to AusAID collecting information concerning the Student or dependants andpassing that information on to other relevant parties, if necessary;

advise AusAID immediately, via the Student Contact Officer at the university, ifthey marry a person who is an Australian or New Zealand citizen, or who haspermanent residence status in Australia or New Zealand. The change in astudents marital status may affect eligibility to maintain the ADS Scholarship, andthe Debt to the Commonwealth may apply if the student does not return to theirhome country for a period of 2 years;

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

be aware that a Debt to the Commonwealth of Australia will be incurred if aStudent fails to return to their home country, or if they apply for PermanentResidence or for a visa to remain in or return to Australia within the two yearperiod; and

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

agree that their ADS may be terminated at any time for failure to makesatisfactory academic progress, failure to comply 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 ofthe AusAID Student Visa or if they apply to change their visa status.

Conditions of Scholarships continued

Subject to your fulfilling these conditions AusAID will provide the following, (either directlyor through the Australian university):

Pre-Course English provision of English for Academic Purposes training prior tocommencement of studies in Australia (including an in-Indonesia stipend)

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

Introductory Academic Program (IAP) the provision of a 4-6 weekIntroductory Academic Program prior to the commencement of studies.

Editorial/tutorial assistance - provided where it is deemed essential to assist

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awardees to pass course subjects.

Travel - payment of an economy airfare from the principal international airports inIndonesia (Jakarta or Denpasar) to the major airport nearest the Australianuniversity and return travel to Indonesia. A separate reunion airfare will beavailable to the student after the successful completion of the first year of study;subsequent reunion airfare entitlements will be available on an annual basis forthe duration of the ADS, except for the final year of the ADS.

Overseas fieldwork- holders of a scholarship where research comprises at least50 percent of the program may receive a return economy class airfare toIndonesia to undertake essential fieldwork.

Contribution to living expenses (in Australia Stipend) - payment of afortnightly contribution to living expenses (CLE).

Overseas Student Health cover (OSHC) - awardee only (awardees arerequired to maintain OSHC for any accompanying family in order to satisfy visarequirements).

Provision of an AusAID Student Visa and Students Dependant visa.

Your university will provide for:

instruction and facilities necessary to complete the specified course

appropriate academic and welfare support for the duration of your studies

airport reception and temporary accommodation arrangements on arrival inAustralia.

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

(NB: to be completed by the staff member within your organisation authorised to releasestaff for overseas study - for example staff from the International Relations Bureau (BKLN)/ Centre for Education and Training / the Planning Bureau / Rector from the university asappropriate. Applicants from outside Jakarta must have the approval and nomination oftheir relevant 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 foracademic training. This training is full-time and compulsory

to release the applicant from work duties after English for academic training tostudy in Australia, and process their 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 toAustralia to cover the cost of medical examinations for the applicant. A medicalexamination is an Australian Immigration requirement to receive 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 theauthorised staff member confirms that the applicant is a lecturer/researcher/key planneror policy maker and that Doctorate level studies are essential for his/her future researchand /or teaching responsibilities.

Name of Ministry/Employer Name of Applicant Applicants Position title

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Applicants Level ofposition inorganisationstructure(eg. Echelon andGolongan)

Datecommenced

/ /

How long have you known the

applicant and in what capacity?

Please make any additionalcomments about the applicant'spotential or personal qualitieswhich you feel would be helpfulto the ADS Selection Team.

Ministry/Agency Representative signature*On behalf of the ministry, I the undersigned, agree to be bound to the above

Full Name Signature & stampPosition Email Mobile Date / /

24. Applicants authorisation, agreement, declaration and signature*

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Authorisation

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

By submitting this form I authorise AusAID, or its appointed managing contractor, toaccess and/or obtain information, including copies of any of my relevant academicrecords/reports from the Australian University(s) that I have attended for the followingpurposes:

for use in the selection process for an Australia Award

to monitor my academic performance at my host university while studying underan 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 anddisclosing extracts of my application (relating to my academic background andachievements, leadership skills and my proposed study program in Australia) inpromotional material in hardcopy and on the Internet. I note that promotional materialmay include, but is not limited to, media releases and information circulated to AusAIDsoffshore Posts and Australian universities, concerning the Australian Development

Scholarships.

I authorise AusAID to disclose the personal information collected in this form to otherAustralian Government departments for the purpose of promoting and managing theAustralian Development Scholarship.

Understanding

I understand and confirm that:

I have read and complied with the Scholarships Handbook and that the contents ofmy application are true and correct

AusAID has the right to vary or reverse any decision regarding an AustraliaDevelopment Scholarships made on the basis of incorrect or incomplete

information

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

Agreement

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

undergo a police or character check before my Australia DevelopmentScholarships is confirmed

immediately provide AusAID with details of any incident that may reflect badly onthe prestige of an Australia Development 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 writtenreports, publications or publicity associated with the Scholarships.

Declaration and acknowledgement

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

I acknowledge that giving false or misleading information is a serious offenceunder 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 documentsattached 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 inthis 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

/ /