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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
State/Province* SULAWESI TENGAH Postal code (if any) 94712
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 / /
Child 2 Will this child accompany you to Australia?* Yes No
Family name OTOLUWA
Given names BARIEQ
Date of birth 16/ 6/ 2004 dd/mm/yyyy Gender Male Female
Country of citizenship INDONESIA
Passport no.
Provide if child has a
*
Issue date / /
Expiry date / /
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Children details continued
Child 3 Will this child accompany you to Australia?* Yes No
Family name
Given names
Date of birth / / dd/mm/yyyy Gender Male Female
Country of citizenship
Passport no.
Provide if child has a
*
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
State/Province* SULAWESI TENGAH Postal code (if any) 94711
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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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?
(maximum 200 words / +
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)
(maximum 200 words / +
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
words / + 350 characters)
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
words / + 350 characters)
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*
Secondary (High School) Vocational, Technical( DIII or DIV )
Under raduate S1 Post raduate S2 or S3
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
Status Complete Pending results Incomplete
3. Qualification name
Level of study
Secondary (High School) Vocational, Technical( DIII or DIV )
Under raduate S1 Post raduate S2 or S3
Name of university
State/Province Country
Language of instruction Start date / /
GPA (if applicable) Obtained / Max End date / /
Status Complete Pending results Incomplete
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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
Start date 1/ 10/ 1995 End date 1/ 12/ 1995
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,
approx 80-100 words limit)
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,
approx 80-100 words limit)
2. Previous position
Position title COORDINATOR O F FOOD AND NUTRITION PROGRAM
Start date 1/ 3/ 2010 End date 1/ 9/ 2011
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)
Start date / / End date / /
2. Organisation Name
Highest position held (if any)
Start date / / End date / /
3. Organisation Name
Highest position held (if any)
Start date / / End date / /
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
/ /