Ads Applicationform 2014 A

7/28/2019 Ads Applicationform 2014 A

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Australia Awards Scholarships2014 Intake Application Form

Instructions

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

> Before completing this form, you must read the Australia Awards Scholarships Policy Handbook

(www.ausaid.gov.au/australia-awards/Documents/scholar-handbook.pdf) and the Indonesia country profile

(http://www.ausaid.gov.au/australia-awards/Documents/indonesia.pdf). Applicants also are encouraged to review all

information available on the Australia Awards Scholarships Indonesia website (www.australiaawardsindo.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.

> One (1) copy of this form and of all attached documents must be received by 19 July 2013 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.

> Australia Awards 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 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 Australia Awards Scholarshiprecipients. 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 page 6 Useful Websites).

> 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 admission 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 25 -

26) 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.

> Applicants must not fill in section 25 of the application form. This section is for use by the Ministry of State

Secretariat of the Republic of Indonesia (KEMSETNEG) 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 19 July 2013

Applications should be submitted as early as possible

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General Information NotesAustralia Awards Scholarships are an important component of Australias investment in education. In Indonesia,Australia Awards Scholarships provide opportunities to study in Australia at POSTGRADUATE level. They are providedto Indonesian citizens to provide enhanced leadership, knowledge and technical skills to the Government of Indonesia,to tertiary institutions and to strategic organisations that are driving sustainable development.

Australia Awards Scholarships have been an important component of the Australian Governments efforts

to reduce poverty and achieve sustainable development since the 1950s. This is achieved through:

developing capacity and leadership skills so that individuals can contribute to development in Indonesia;

building people-to-people linkages at individual, institutional and national levels between Indonesia and Australia.

There are a number of supplementary programs associated with Australia Awards Scholarships in Indonesiaincluding the Australia Awards Leadership Program and the Allison Sudradjat Prize.

Public applicants are from government organisations, state universities and state owned enterprises and must beapproved by training or foreign cooperation bureaus (BKLN) of their local or central agencies (see page 23). Publicapplicants from government agencies outside Jakarta may apply directly to the AUSTRALIA AWARDSSCHOLARSHIPS program office with the approval of their relevant KakanwilorKadinas and approval from BupatiorGovernor (or representative) where necessary. Calon Pegawai Negeri Sipil (CPNS) are not eligible to apply.

Open applicants are from private organisations, private universities and also include recent university graduates. No

government approval is required and applications are to be submitted directly to the Australia Awards office. A letter ofsupport from the applicants home agency, institution or private university may be included with the application.Publicservants (pegawai negeri) cannot apply as open applicants.

Targeted and Non-Targeted Category

AUSTRALIA AWARDS SCHOLARSHIPS are awarded as Targetedor Non-Targeted. Up to 70% of AUSTRALIAAWARDS SCHOLARSHIPS are Targeted; available for nominated staff from Government of Indonesia Key Agencies,Targeted Sectors and from AusAID Geographic Focus Areas1. Further information on each of these sub-categories isavailable at www.australiaawardsindo.or.id

At least 30% of AUSTRALIA AWARDS SCHOLARSHIPS are Non-Targeted available for public servants and non-public servants outside the AusAID Geographic Focus Areas.

Scholarships are for full-time study for a Masters or Doctorate degree from Australian tertiary institutions. The

scholarship 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.

Social inclusionEligible candidates with a disability or from organisations working with the disabled are encouraged to apply. Womenand candidates within AusAID Geographic Focus Areas are also encouraged to apply.

EligibilityIN GENERAL CANDIDATES MUST:

> be an Indonesian citizen and be residing in and applying for the scholarship from Indonesia

> 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 inAustralia

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

> not be applying for a visa to live in Australia

> not be applying for another long-term Australia Award unless they have resided outside Australia for twice the

length of the total time that they were in Australia (for example, a previous Australia Awards Scholarship recipient

in Australia for four years will not be eligible to apply for another Australia Awards Scholarship until they have

resided outside Australia or back in Indonesia for eight years)

> have satisfied any specific criteria established by Indonesia or government of Indonesia

> not be current serving military personnel

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

visa and

1Aceh, Nusa Tenggara Timur, Nusa Tenggara Barat, Papua, West Papua

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

undertaken.

SPECIFICALLY, CANDIDATES MUST:

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

> at the application closing date, be not older than 42 years of age

>

have a Grade Point Average (GPA) of at least 2.9 on a scale of maximum 4.0 (2.75 for applicants from AusAIDGeographic Focus Areas) and an English language proficiency of at least 5.0 in IELTS (500 in paper-based TOEFL

or 61 in internet based TOEFL - IBT). The IELTS or TOEFL result must be current (no earlier than 2012). No other

English language test will be accepted (specifically the result from a TOEFL Prediction Test is not accepted).

Contact details of the English language test centre must be provided for verification of test results.

> have a Grade Point Average (GPA) of at least 2.75 for recipients with a disability as declared on the AUSTRALIA

AWARDS SCHOLARSHIPS application form.

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

o already hold an undergraduate degree, if applying for a Masters

o already have a Masters, if applying for a Doctorate

> 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 areas (PDA). The PDA

relate directly to the strategic objectives contained in the Australia and Indonesia Country Strategy. An indicativelist of the areas for study follows.

AustraliaIndonesiaPartnershipPriority Areas(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, environmental

governance and response toclimate change.

Strengthening thecapacity, accountabilityand responsiveness oflegal, democratic andoversight institutions, andimproving localgovernment and public

financial management.

Better quality, accessand governance ineducation, and betterhealth access andsystems

Improving responses tohumanitarian needs,emergencies andvulnerability todisasters, andimproving capacity toensure transport

security and to counterthreats fromtransnational crime.

AustraliaIndonesiaPartnershipPriority Fieldsof Study

Natural Resource

Management

Mining

Agriculture

Aquaculture/fisheries

Forestry

Climate Change

Economics

Infrastructure Planning

Water and Sanitation

Rural Growth

Small and medium

enterprise

Law, legal and

judicial systems

Political Science and

Government

Public administration

Public expenditure

management

Public Sector

Reform

Environmental Law

Anti-corruption

Decentralisation

Monitoring &Evaluation

Communicable

Disease Prevention

Health

Management

Health Services

Maternal and Child

Health

Women and

Gender Studies

Disability Services

Public Health

Education and

Training Education

Management

Human Resource

Childhood Special

Education

Conflict Resolution

Disaster

Prevention andManagement

Transport Safety

Transnational

Crime Prevention

Studies

International

Studies

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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 S trategy at: http://www.ausaid.gov.au/Publications/Pages/Australia-Indonesia-Partnership-Country-

Strategy-2008-13-english.aspx

Candidates considering study for particular professions should note that AUSTRALIA AWARDS SCHOLARSHIPS

does not include the practical training period required for professional registration, e.g. medical internships, legal

articles etc. Successful recipients 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, and cultural adaptability. A critical consideration will be how well the AUSTRALIA

AWARDS SCHOLARSHIPS applicant is able to explain the relevance 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 recipients is subject to

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

SELECTION QUOTAS:

> Up to 70% of awards will be offered to applicants from the Targeted Category including up to 30% of this number

from AusAID Geographic Focus Areas

> At least 30% of awards will be offered to applicants from the Non-Targeted Category,

> 85% of awards at Masters level and up to 15% of awards at Doctorate (PhD) level. (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).

> 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 AUSTRALIA AWARDS SCHOLARSHIPS. 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 AUSTRALIA AWARDS SCHOLARSHIPS 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 AUSTRALIA

AWARDS SCHOLARSHIPS 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.

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 be4
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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 in Indonesia, not the visa expire date.

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

Australia (including an in-Indonesia stipend)

> In-Indonesia Stipend for the period from the commencement of Pre-Course English to the date of recipientmobilisation. This does not apply to any deferral period.

> Medical examination and x-ray costs in order to comply with Student Visa requirements

> AusAID Student Visa and Student Dependant Visa

> Outward Airfare (economy- one way) from the airport closest to the recipients home location to the international

airport closest to the Australian university selected for study by the recipient

> Overseas Student Health Cover (OSHC) - recipient only (recipients are required to maintain OSHC for any

accompanying family in order to satisfy visa requirements).

> Establishment Allowance payable into the recipients bank account after arrival in Australia

>

Contribution to Living Expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses(CLE).

> Introductory Academic Program (IAP) for a period of 4-6 weeks undertaken prior to the commencement of Masters

or PhD studies

> Masters OR PhD Tuition Fees including all compulsory fees for the course in which the recipient is accepted into

> Supplementary Academic Support - provided where it is deemed essential to assist recipients to pass course

subjects.

> 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.

> Reunion Airfare - is available to a single recipient 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 AUSTRALIAAWARDS SCHOLARSHIPS, except for the final year of the AUSTRALIA AWARDS SCHOLARSHIPS.

> Homeward Airfare (economy- one way) from the international airport closest to the Australian university selected

for study by the recipient to the airport closest to the recipients home location..

Family Entry

Recipients 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 recipient's arrival.

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Useful websites

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

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

Australia Awards Scholarship (AUSTRALIA AWARDS SCHOLARSHIPS) Indonesia:

http://www.australiaawardsindo.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 and Courses

for

Overseas Students (CRICOS): http://cricos.deewr.gov.au

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

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

Follow Australia Award Scholarships updates at Greg Moriarty @DubesAustralia

The AUSTRALIA AWARDS SCHOLARSHIPSApplication Process

6

Step 1Applicant sends complete

AUSTRALIA AWARDSSCHOLARSHIPS application

form toAustralia Awards Office by

19 July 2013.

Step 2Applicant is notified of

the result of selection forinterview by

mid December 2013.

Step 3Applicant selected for

interview receives

information of interview/IELTS test date/location.

Step 4Applicant attends

interview and IELTS testin January 2014.

Step 5Applicant is advised of

the result of their AUSTRALIAAWARDS SCHOLARSHIPS

application by February 2014.
http://www.immi.gov.au/http://www.studyinaustralia.gov.au/http://cricos.deewr.gov.au/http://www.ets.org/toeflhttp://www.immi.gov.au/http://www.studyinaustralia.gov.au/http://cricos.deewr.gov.au/http://www.ets.org/toefl


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Australia Awards Scholarships2014 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* YUSTIYANTY 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* MONOARFA

Date of birth* 6/ 3/ 1973 dd/mm/yyyy Gender* Male Female

Place of birth* (State/province) GORONTALO

Which country are you living in now?* INDONESIA

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* JLN. WOLTER MONGINSIDI NO. 43

Address line 2

Address line 3

Town/City* LUWUK KABUPATEN BANGGAI

State/Province* SULAWESI TENGAH Postal code (if any) 94711

Country* INDONESIA

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.* 0461 23535 Work phone no. : (0461) 3128069

Mobile no. 081341298923 Fax no. (if any)

Email 1 [email protected]

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* JL. AHMAD YANI NO. 2D

Address line 2

Address line 3

Town/City* LUWUK KABUPATEN BANGGAI


Country* INDONESIA

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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

universit where ou want to stud .

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

Family names* OTOLUWA

Date of birth* 21/ 1/ 1967 dd/mm/yyyy Gender* Male Female

Passport no.

Provide if spouse

*

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 Citizenshipwebsite or by contacting the

university where you want to study.

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

Family name OTOLUWA

Given names BRYAN

Date of birth 4/ 11/ 2002 dd/mm/yyyy Gender Male Female

Country of citizenship INDONESIA

Passport no.

Provide if child has a

*

Issue date / /

Expiry date / /


Family name OTOLUWA

Given names BARIEQ

Date of birth 16/ 6/ 2004 dd/mm/yyyy Gender Male Female

Country of citizenship INDONESIA

Passport no.


*

Issue date / /

Expiry date / /

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Children details continued


Family name

Given names

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

Country of citizenship

Passport no.


*

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* OTOLUWARelationship to

you*HUSBAND

Given name* ANANG Gender* Male Female

Home phone* (0461) 23535 Work phone (0461) 22248

Mobile phone 085656045000 Fax (if any)

Email 1 [email protected]

Email 2

Address line 1* JL. WOLTER MONGINSIDI NO. 43

Address line 2

Address line 3

Town/City* LUWUK


Country* INDONESIA 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 ASIAN DEVELOPMENT BANK

Start date APRIL 2007 End date APRIL 2009 Country INDONESIA

Qualification (if applicable) MASTER OF NUTRITION

University HASANUDDIN UNIVERSITY

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Previous scholarships continued

2. Scholarship/fellowship title WORLD HEALTH ORGANIZATION FOUNDATION

Start Date MARCH 1999 End date OCTOBER Country INDONESIA

Qualification (if applicable) BACHELOR OF NUTRITION

University BOGOR AGRICULTURAL INSITITUTE

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 AUSTRALIA AWARDS SCHOLARSHIPS? 2

Have you previously been interviewed by AUSTRALIA AWARDS

SCHOLARSHIPS?* Yes No

If Yes, in which years?

8. Disability

AusAID strongly encourages applications from people with disability who are otherwise eligible for a Scholarship. Under the Disability

Discrimination Act, Australian education institutions have to provide 'reasonable adjustments' to students with disability to assist access to study.

To assess the likely support needs, appropriate assistance, and the capacity of relevant institutions to provide the assistance, recipients with a

disability/special need must provide details of the disability and/or special need when they accept their offer. This information is bound by

Australian privacy laws and will be disclosed only for the purpose of facilitating an accessible barrier-free learning environment.

Modifications to physical or learning environments, including additional educational supports such as sign interpreters and captioning, may be

available depending on the relevant Institution's capacity. AusAID will advise the Institution of any special requirements associated with a

Recipient so that the Institution can pass these details to the Institutions Disability Liaison Officer prior to the Recipient arriving on-campus.

Where an Institution is not able to provide the assistance requested, other Institutions may be recommended.

Do you identify as having a disability or do you work in a disability-focused organisation?*

neurological, learning disabilities, physical disfigurement, and the presence in the body of

disease-causing organisms

(http://www.hreoc.gov.au/disability_rights/dda_guide/who/who.html)

Yes No

If yes, please provide details if you require special assistance or equipment to participate in the Scholarship selection

rocesses or to live and undertake studies in Australia?

9. Are you applying for an AUSTRALIA AWARDS SCHOLARSHIPS as a public or open applicant? *

Public

If Public, please indicate if your application is from:

Government department

State-owned enterprise

State university

Open

If Open, please indicate if your application is from:

Private university

Private organisation

Private individual

10. Proposed study program*

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AusAID will consider offering you a scholarship only if your course of study will contribute to the long-term needs of yourcountry. Note that the proposed program of study should be appropriate to your academic qualification and workexperience.

Requested Level of study*(You will not be allowed toupgrade your course from thelevel at which you are first

placed).

Masters

Doctorate (PhD)

Type of study*(Masterscoursework program can contain aresearch project up to 30% of theMasters. Candidate decide the topic

during 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 you should pursue Doctorate

studies? (Recommended) Yes No

Proposed field of study*

You are required to:

Identify the Priority Development Area (PDA) for your proposed studies. (Please tick one box only).

Identify the Priority Field of Study (PFS) from the list of preferred PFS provided (Please tick one box only).

If necessar , ou ma nominate another Field of Stud in 'other' Please tick other and rovide detail .

AustraliaIndonesiaPartnershipPriorityAreas (PDA)*

Sustainable Growthand EconomicManagement

Democracy Justiceand GoodGovernance

Investing in People Safety and Peace

Descriptionof PDA

Improving economicpolicy and management,reducing constraints togrowth in infrastructureand productivity, andimproving natural

resource management,environmentalgovernance and responseto climate change.

Strengthening thecapacity, accountabilityand responsiveness oflegal, democratic andoversight institutions, andimproving local

government and publicfinancial management.

Better quality, access andgovernance in education,and better health accessand systems

Improving responses tohumanitarian needs,emergencies and vulnerabilityto disasters, and improvingcapacity to ensure transportsecurity and to counter

threats from transnationalcrime.

AustraliaIndonesiaPartnershipPriorityFields ofStudy (PFS)*

Natural ResourceManagement

Mining

Agriculture

Aquaculture/fisheries

Forestry

Climate Change

Economics

Infrastructure

Planning

Water and Sanitation

Rural Growth

Small and medium

enterprise

Law, legal and judicialsystems

Political Science andGovernment

Public administration

Public expendituremanagement

Public Sector Reform

Environmental LawAnti-corruption

Decentralisation

Monitoring &Evaluation

CommunicableDisease Prevention

Health Management

Health Services

Maternal and ChildHealth

Women and GenderStudies

Disability ServicesPublic Health

Education andTraining

EducationManagement

Human Resource

Childhood SpecialEducation

Conflict Resolution

Disaster Prevention andManagement

Transport Safety

Transnational CrimePrevention

Studies

International Studies

Other,please specify:

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Proposed study program* continued

Have you obtained information from the AUSTRALIA AWARDS SCHOLARSHIPS

Information CD, or from the AUSTRALIA AWARDS SCHOLARSHIPS 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.

1. I HAVE COLLECTED SUFFICIENT INFORMATION FROM WEBSITE OF RELEVANT UNIVERSITIES INAUSTRALIA (UNIVERSITY OF GRIFFITH AND BOND UNIVERSITY).

2. FIND A SUITABLE COURSE AT TWO AUSTRALIAN UNIVERSITIES

3. I APPROACHED THE GRIFFITH UNIVERSITY AND BOND UNIVERSITY BY EMAIL WITH A DRAFT

RESEARCH PROPOSAL TO FIND POTENTIAL SUPERVISORS , AND I'VE ALREADY GOT POTENTIAL

SUPERVISOR FROM BOND UNIVERSITY AND FROM GRIFFITH UNIVERSITY.

4. RECEIVE LETTER OF SUPPORT FROM BOND UNIVERSITY

5. I CONTACTED INDONESIAN STUDENTS IN AUSTRALIA TO GET INFORMAL INFORMATION ABOUT

STUDYING IN AUSTRALIA.

6.GET APPROVAL FROM THE HEAD OF HASANUDDIN FOOD AND NUTRITION RESEARCH CENTER AND

MY FORMER DIRECT SUPERVISOR TO STUDY IN MATERNAL AND CHILD NUTRITION WILL BE AN

ADVANTAGE FOR INDONESIA ESPECIALLY TO DEVELO P MORE NUTRITION RESEARCH. HE SUPPORTS

ME TO APPLY FOR THE STUDY IN AUSTRALIA, AS ONE OF THE BEST PLACE FOR STUDY OF NUTRITION.7. READ THE NUTRITION JOURNALS MADE BY AUSTRALIAN RESEARCHERS

8. READ AUSTRALIAN GOVERNMENT WEBSITE

AUSTRALIA AWARDS SCHOLARSHIPS - Australian Universities List

Following Australian universities are under contract to AusAID to provide courses for AUSTRALIA AWARDS

SCHOLARSHIPS recipients. Recipients 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 AUSTRALIA AWARDS SCHOLARSHIPS Information CD which can be obtained fromthe Australia Awards Office or AUSTRALIA AWARDS SCHOLARSHIPS website http://www.australiaawardsindo.or.id.

Preference 1*

DOCTOR OF PHILOSOPHY (FACULTY OF HEALTH SCIENCES AND MEDICINECourse title or particular focusarea within your identifiedproposed Field of Study.*

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http://cricos.deewr.gov.au/http://cricos.deewr.gov.au/http://cricos.deewr.gov.au/http://www.australiaawardsindo.or.id/http://cricos.deewr.gov.au/http://cricos.deewr.gov.au/http://www.australiaawardsindo.or.id/


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CRICOS code (if applicable)* 063150J Australian University(if applicable)

BOND UNIVERSITY

Course duration (weeks)(if applicable)

208

Minimum Englishlanguage proficiencyrequired for the course

Proposed preferences continued

Preference 2*

DOCTOR OF PHILOSOPHY IN PUBLIC HEALTHCourse title or particular focusarea within your identifiedproposed Field of Study.*

CRICOS code (if applicable)* 062206F Australian University(if applicable)

GRIFFITH UNIVERSITY

Course duration (weeks)(if applicable)

208Minimum 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 that you would like to include in your

choice?Yes No

If "Yes" please give details. (Note that AUSTRALIA AWARDS SCHOLARSHIPS 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 of Research 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)

PERICONCEPTUAL MULTI MICRONUTRIENTS IN PREVENTION OF INTRA UTERINEGROWTH RETARDATION.

What is the background to

the research being

proposed? (maximum 150

words / + 1,000

characters)

ONE OF THREE (37%) INDONESIAN CHILDREN UNDER-FIVE SUFFER FROM

STUNTED GROWTH, A PRIMARY MANIFESTATION OF CHRONIC MALNUTRITION.

STUNTING CONTRIBUTES TO 14.5% OF ANNUAL DEATHS AND 12.6% OF

DISABILITY ADJUSTED LIFE-YEARS IN UNDER-FIVE CHILDREN. TO OVERCOME

THIS PROBLEM, MULTI MICRONUTRITION (MMN) INTERVENTION DURING PRE

CONCEPTION IS IMPORTANT, BECAUSE IT TURNS ON WHEN PREGNANT,

MOTHERS IN INDONESIA HAS BEEN IN A STATE OF MALNUTRITION. THIS

INTERVENTION IS EXPECTED TO PREVENT INTRAUTERINE GROWTHRESTRICTION (IUGR). IF THIS CAN BE PREVENTED, THEN THE FETUS WILL

BORN NORMAL, HEALTHY AND AVOID FROM STUNTING. IUGR IS A FREQUENT

CAUSE OF IMPAIRED GROWTH DURING THE REST OF THEIR CHILDHOOD,

ADOLESCENCE AND ADULT LIFE. THE PREVALENCE IUGR IN INDONESIA IS ABOUT

8%. HOWEVER, THERE IS NO RESEARCH SHOWED THAT MMN INTERVENTION IN

PERICONCEPTIONAL AFFECT IUGR. THEREFORE , THIS RESEARCH NEEDS TO BE

CONDUCTED.

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)

MULTI MICRONUTRIENT ON PRECONCEPTION IS WISHED TO INCREASE

NUTRITIONAL STATUS OF PREGNANT WOMEN. FULLFILMENT OF MICRONUTRIENT

WILL PREVENT IUGR . THIS EFFORT IS NEEDED TO REDUCE LOW BIRTH WEGHT,

INFANT MORTALITY RATE, STUNTING, AND LONG CONSEQUENCES SUCH AS

HYPERTENSION, CORONARY HEART DISEASE AND DIABETES. HOWEVER, THERE IS

NO EVIDENCE THAT MMN HAS EFFECT ON PREVENTING IUGR. THIS RESEARCH

HAS OBJECTIVE TO FILL THE GAP OF THIS KNOWLEDGE.

What hypothesis are you

testing in your proposed

research? (maximum 50

words / + 350 characters)

CONCENTRATION UE 3 (UNCONJUGATED ESTRIOL ) IN PREGNANT WOMEN WHO

RECEIVES MULTIMICONUTRIENT (MMN) IS HIGHER THAN THOSE WHO RECEIVE

IRON FOLIC ACID (IFA).

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What are the objectives of

the proposed research?


1,300 characters)

GENERAL OBJECTIVE : TO ASSESS THE EFFECT OF PERICONCEPTIONAL

MULTIMICRONUTRIENT (MMN) ON FETAL GROWTH IN COMPARISON WITH IRON

FOLIC ACID (IFA) CAPS .

SPECIFIC PURPOSE : COMPARING THE CONCENTRATION OF UNCONJUGATED

ESTRIOL (MARKER OF FETAL GROWTH) BETWEEN MMN AND IFA GROUP.

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Research proposal details

What is the

methodology/structure in

your proposed research?

(include comments on

measurements, data

sources, methods ofanalysis and timelines)


1,300 characters)

STUDY DESIGN IS DOUBLE BLIND, RANDOMIZED COMMUNITY TRIAL. THE

INTERVENTION WILL BE DIVIDED INTO TWO GROUPS: THE INTERVENTION GROUP

WILL RECEIVE MMN AND CONTROL ARE GIVEN IFA. U3E DATA TAKEN FROM THE

SERUM OF PREGNANT WOMEN AND EXAMINED BY RADIOIMMUNOESSAY.

ANALYSIS USING UNPAIRED T TEST. FIELDWORK TO INDONESIA WILL BE

CONDUCTED TO CARRY OUT RECALL CONSUMPTION 24 HOURS , THEMEASUREMENT OF ANTROPOMETRIC , ENUMERATOR AND LABORATORY ANALYST

INVOLVING GOVERNMENT INSTITUTION RELATED TO MATERNAL NUTRITION

ISSUES IN INDONESIA SUCH AS HEALTH DEPARTMENT REGENCY, COMMUNITY

HEALTH CENTER AND EDUCATIONAL INSTITUTIONS. THIS STUDY WILL TAKE 1

YEAR.

Have you published any

research to date? (include

texts, journal articles

providing full citation)

- INTERNATIONAL CONGRESS OF NUTRITION IN THAILAND, 2009 (POSTER

PRESENTATION)

- INTERNATIONAL SYMPOSIUM ON NUTRITION AND 6 TH ASIA PACIFIC CLINICAL

NUTRITION IN INDONESIA, 2009 (ORAL PRESENTATION).

Which university do you

consider appropriate for

your proposed studies?

Why? (maximum 50


GRIFFITH UNIVERSITY AND BOND UNIVERSITY.

-THEY HAVE SPECIAL EXPERT TO PURSUE THE FIELD OF MATERNAL AND CHILD

NUTRITION

- THEY HAVE INTERNATIONAL REPUTATION IN THE FIELD OF NUTRITION

- THEY HAVE MANY SCIENTIFIC PUBLICATIONS IN THE FIELD OF NUTRITION

- I'VE BEEN DOING A CORRESPONDENCE WITH TWO POTENTIA L SUPERVISORS

- MY FORMER DIRECT SUPERVISOR OFTEN IN COOPERATION WITH MY

POTENTIAL SUPERVISION (PROF. HUGHES-BOND UNIVERSITY)

Have you considered a

possible research

supervisor? Why thisselection?(maximum 50


YES. MY SUPERVISOR ARE PROF. ROGER HUGHES AT BOND UNIVERSITY AND

PROF. FARUK AHMED AT GRIFFITH UNIVERSITY. THEY CURRENTLY ARE

TEACHING ABOUT NUTRITION THROUGH THE LIFECYCLE AND RESEARCHEXPERTISE ON MICRONUTRIENTS AND HEALTH , IT SEEMS LIKE AN EXCELLENT

FIT FOR MY RESEARCH. BOTH OF THEM HAVE BEEN DECLARED READY TO

BE MY SUPERVISOR.

What is the relevance of

the proposed research to

Indonesia?

THE BEST I KNOW, THERE ARE ONLY TWO STUDIES ON THE PROVISION OF MULTI-

MICRONUTRIENT IN PERICONCEPTIONAL, WHICH ASSESS THE INFLUENCE ON THE

NUTRITIONAL STATUS OF PREGNANT WOMEN AND MATERNAL DNA DAMAGE. THE

RESULTS OF MY RESEARCH WILL CONTRIBUTE TO THE GOVERNMENT OF

INDONESIA, ESPECIALLY IN FORMULATING POLICIES / PROGRAMS TO ADDRESS

NUTRITION PROBLEMS IN PREGNANT WOMEN, AND STUNTING LONG-TERM DEAL.

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).

FIELDWORK IN INDONESIA WILL BE CONDUCTED FOR A PERIOD OF ABOUT NINE MONTHS DURING THE

SECOND YEAR OF MY STUDY. THE FIELDWORKS CONSISTS OF :

1. COLLECTING BASELINE AND END LINE DATA, DIETARY INTAKE OF MOTHERS, AND

ANTROPHOMETRIC MEASUREMENT.

2. CHECKING PREGNANT WOMEN, ANTENATAL CARE, CONTROLLING CADRE.

3. REQRUITMENT OF PARTICIPANT, DISTRIBUTE MMN AND IFA, CONTROLLING COMPLIANCE.

4. COLLECTING BLOOD SAMPLES AND U3E MEASUREMENT.

What is the duration of your proposed fieldwork? (if known) 40 Weeks

In which country will you undertake the proposed fieldwork? INDONESIA

Proposed fieldwork supervisor (if known) PROF. DR. Dr. ABDUL RAZAK THAHA, MSC

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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.

One certified copy 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* MASTER OF NUTRITION

Level of study*

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

Under raduate S1 Post raduate S2 or S3

Name of university* HASANUDDIN UNIVERSITY

State/Province SOUTH SULAWESI Country* INDONESIA

Language of instruction* BAHASA INDONESIA Start date * 4/ 4/ 2007

GPA (if applicable) Obtained 3.80 / Max 4.00 End date* 30/ 3/ 2009

Status Complete Pending results Incomplete

2. Qualification name* BACHELOR OF NUTRITION

Level of study*



Name of university* BOGOR AGRICULTURAL UNIVERSITY

State/Province WEST JAVA Country* INDONESIA

Language of instruction* BAHASA INDONESIA Start date* 3/ 9/ 1996GPA (if applicable) Obtained 2.84 / Max 3.00 End date* 30/ 3/ 2001


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 61 in

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

2012 or 2013 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 university verifying the language of instruction.

Have you taken an IELTS or TOEFL test? Yes No

Test name (e.g.

IELTS or TOEFL)TOEFL ITP

Date test

taken07/07/2012 Overall

score570

Test Centre/location CLS FBS UNM Makassar Phone +62411- 888860 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 Word Processor Dos System

Start date 1/ 7/ 1995 End date 1/ 9/ 1995

Course name 2 Lotus 123 Dos System


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.

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Position title* NUTRITIONIST

Organisation* DISTRICT HEALTH OFFICE

Level of position in

organisation structure

(eg. Echelon and Golongan)

IV/A Date commenced* 1/ 10/ 2012

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

Briefly describe the work of

your organisation and the

service it provides.

DISTRICT HEALTH OFFICE HAS THE MAIN TASK CARRYING OUT THE AFFAIRS OF

LOCAL GOVERNMENT IN HEALTH SECTOR, BASED ON THE PRINCIPLE OF

AUTONOMY .

Briefly describe your current

duties and responsibilities

(max 500 characters, approx80-100 words limit)

W

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

If Yes, what role and

responsibilities do you

expect to undertake after

your academic studies?(max 500 characters,


What specific tasks do you

anticipate being able to

undertake after your

academic studies? (specify

at least 3) (max 500characters, approx 80-100

words limit)

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16. Previous relevant employment

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

1. Previous position

Position title KEPALA BIDANG KONSUMSI DAN KEAMANAN PANGANOrganisation BADAN KETAHANAN KABUPATEN BANGGAI

Start date / / End date / /

Duties/responsibilities

(max 500 characters,


2. Previous position

Position title COORDINATOR O F FOOD AND NUTRITION PROGRAM


Organisation FOOD SECURITY DEPARTMENT, BANGGAI REGENCY

Duties/responsibilities

(max 500 characters,approx 100 words limit)

1). COORDINATE TO UTILIZE THE LOCAL FOOD AS SOURCE OF NUTRITION FOR

HOUSEHOLD CONSUMPTION IN RURAL AREA AT BANGGAI REGENCY2). GIVE COUNSELING ABOUT NURITION AND FOOD SAFETY IN RURAL AREA AT

BANGGAI REGENCY.

17. Interview Centre *

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

Jakarta

Yogyakarta

Surabaya

Denpasar

Medan/Banda Aceh

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?*

1. AUSTRALIA HAS AN EXCELLENCE IN EDUCATION STANDARDS SYSTEM AND HAS AN INTERNATIONAL REPUTATION, NO

DOUBT; AND MANY OTHER COUNTRIES THAT MAKE AUSTRALIA A REFERENCE TO IMPROVE THEIR EDUCATIONSYSTEMS.

2. EDUCATIONAL QUALIFICATIONS IN AUSTRALIA ARE INTERNATIONALLY RECOGNIZED. AUSTRALIAN QUALIFICATIONFRAMEWORK (AQF) IS A SYSTEM OF NATIONAL POLICIES. WITH THE AQF WE CAN DETERMINE THE APPRORIATE COURSEOF STUDY WITH THE EDUCATION AND CAREER WE CHOOSE.

3. AUSTRALIA KNOWN AS A HARMONIOUS NATION, THE AUSTRALIAN COMMUNITY RECOGNIZES THAT ALL PERSONS AREEQUAL, REGARDLESS OF GENDER OR RACE. DEMOCRATICALLY ELECETED GOVERNMENT, AND NOT RULED BY THEMILITARY NOR BASED ON RELIGION.

4. AUSTRALIA USING ENGLISH AS LANGUAGE OF INSTRUCTION.5. HAVE QUALITY OF ENVIRONMENT AND HEALTHLY EARNING ATMOSPHERE.6. AUSTRALIA HAS LEGAL PROTECTION FOR THE QUALITY OF EDUCATION FOR THE INTERNATIONAL STUDENTS.

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

AFTER GETTING MY PhD, I HOPE MY KNOWLEDGE WILL INCREASE IN THE FIELD OF MICRONUTRIENTS AND ITS IMPACTS TOFETAL GROWTH. IN ADDITION, MY SKILLS ALSO IMPROVED IN CONDUCTING RESEARCH ON NUTRITION INTERVENTION.I WILL USE THESE CAPABILITIES TO ADVOCATE PEOPLE OR STAKEHOLDERS EFFECTIVELY AND MAKE THEM BELIEVE ABOUTTHE ROLE OF NUTRITION DURING THE PERICONCEPTIONAL PERIOD AND THEY ARE WILLING TO PROVIDE SUFFICIENT BUDGETFOR GRANTING MULTI MIKRONUTRIENT IN THAT PERIOD.

3. How have you contributed to solving a challenge and to implementing change or reform? (Be specific andinclude: what aspect/s of your leadership knowledge, skills and practice you consider to be well established andeffective; which people or organisations you worked with to solve the problem; and what creative methods wereused.)?*

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Supporting statement continued

4. What specific priority will you contribute to on your return home and how do you intend to do so?*

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

AusAID Posts or with AusAIDsmanaging contractors?*

Yes No

If `Yes please expand.

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

le al action?*to live and undertake studies in Australia? Yes No

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

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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)








20. Communication*

Where did you first learn of the Australia Awards 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)

AUSTRALIA AWARDS

SCHOLARSHIPS website

AUSTRALIA AWARDS

SCHOLARSHIPS OfficeAusAID Office

Friend, relative or colleague DIISRTE Office GoI State Secretariat Office

Education Agent (specify)Home institution or

university (specify)

AusAID project office

(specify)

Workplace or nominating

authority (specify)

AUSTRALIA AWARDS

SCHOLARSHIPS

information CD-ROM

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.

ONE COPY of the completed application form.

At least one copy of the application form should have certified* copies attached of the relevant documentslisted below.

Where original documents are not in English, you must provide certified* copies of official English translationsif 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 AUSTRALIA AWARDS SCHOLARSHIPS 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 or TOEFL English language test results (a test result obtained

in 2012 or 2013 will be considered current). TOEFL prediction test is NOTaccepted.

Yes N/A

Masters applicants must also attach certified DIII degree certificate and transcript if

using DIV or S1 extension certificate/transcriptYes N/A

Doctorate applicants must also attach certified S1 degree certificate and 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 ofresults

Yes 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 scholarship

award. If you have any problems understanding Section 22, 23 and 24 you are strongly advised to seek clarification ofthese 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 Australia Awards Scholarship, you will be asked to:

take up the AUSTRALIA AWARDS SCHOLARSHIPS 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 AUSTRALIA AWARDS

SCHOLARSHIPS;

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 AUSTRALIA AWARDS SCHOLARSHIPS (apart from holidays, reunion

visits or fieldwork visits to their home country);

complete their AUSTRALIA AWARDS SCHOLARSHIPS award within the period stipulated in their Student

Contract;

only undertake the approved program for which the AUSTRALIA AWARDS SCHOLARSHIPS 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 the

AUSTRALIA AWARDS SCHOLARSHIPS 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 for examinations;

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

Visa;

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 approved

program 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 to

other relevant parties, if necessary;

advise AusAID immediately, via the Student Contact Officer at the university, if they marry a person who is an

Australian 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 AUSTRALIA AWARDSSCHOLARSHIPS, and the Debt to the Commonwealth may apply if the student does not return to their homecountry 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 home

country, or if they apply for Permanent Residence or for a visa to remain in or return to Australia within the twoyear 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 AUSTRALIA AWARDS SCHOLARSHIPS may be terminated at any time for failure to makesatisfactory academic progress, failure to comply with the laws of Australia, misconduct, breaches of the contractbetween the Student and the Commonwealth of Australia including breaches of the conditions of the

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AUSTRALIA AWARDS SCHOLARSHIPS or of the AusAID Student Visa or if they apply to change their visastatus.

Conditions of Scholarships continued

Subject to your fulfilling these conditions AusAID will provide the following, (either directly or through the Australianuniversity):

Pre-Course English provision of English for Academic Purposes training prior to commencement of studies in

Australia (including an in-Indonesia stipend)

In-Indonesia Stipend for the period from the commencement of Pre-Course English to the date of recipient

mobilisation. This does not apply to any deferral period.

Medical examination and x-ray costs in order to comply with Student Visa requirements AusAID Student Visaand Student Dependant Visa

Outward Airfare (economy- one way) from the airport closest to the recipients home location to the international

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airport closest to the Australian university selected for study by the recipient

Overseas Student Health Cover (OSHC) - recipient only (recipients are required to maintain OSHC for any

accompanying family in order to satisfy visa requirements).

Establishment Allowance payable into the recipients bank account after arrival in Australia

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

expenses (CLE).

Introductory Academic Program (IAP) for a period of 4-6 weeks undertaken prior to the commencement of

Masters or PhD studies

Masters OR PhD Tuition Fees including all compulsory fees for the course in which the recipient is accepted

into

Supplementary Academic Support - provided where it is deemed essential to assist recipients to pass course

subjects.

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.

Reunion Airfare - is available to a single recipient 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 AUSTRALIAAWARDS SCHOLARSHIPS, except for the final year of the AUSTRALIA AWARDS SCHOLARSHIPS.

Homeward Airfare (economy- one way) from the international airport closest to the Australian university

selected for study by the recipient to the airport closest to the recipients home location.

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 in Australia.

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 and approval from Bupati or Governor (or representative) where necessary.)

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 of

medical 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 DINAS KESEHATAN KABUPATEN BANGGAI

Name of Applicant YUSTIYANTY MONOARFA

Applicants Position title NUTRITIONIST

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Applicants Level of position

in organisation structure

(eg. Echelon and Golongan)

IV A Date commenced / /

How long have you known the applicant and

in what capacity?

4 YEARS

Please make any additional comments about

the applicant's potential or personal qualities

which you feel would be helpful to the

AUSTRALIA AWARDS SCHOLARSHIPS

Selection Team.

Ministry/Agency Representative signature*

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

Full Name DR. WINARNY ABDULLAH, SpA Signature & stamp

Position KEPALA DINAS KESEHATAN KABUPATEN BANGGAI

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 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 Australia Awards

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 inAustralia) 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, concerning theAustralia Awards 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 Australia Awards 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 and

correct

AusAID has the right to vary or reverse any decision regarding an Australia Awards Scholarships made on the

basis of incorrect or incomplete information

Decisions of the selection panel are final and confidential and no correspondence about outcomes of the

selection process will be entered into.

Agreement

If successful in gaining an Australia Scholarships, I agree that I will: undergo a police or character check before my Australia Awards Scholarships is confirmed

immediately provide AusAID with details of any incident that may reflect badly on the prestige of an Australia

Awards Scholarships

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

use the funds for the purposes granted

acknowledge the assistance given by the Australian Government in any written reports, publications or publicity

associated 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 1995of the Commonwealth of Australia.

Full Name Signature Date

YUSTIYANTY MONOARFA / /

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

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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 Australia Awards Scholarship.

Name of certifying officer

Title

Organisation

Official Stamp Signature Date

/ /