Title Given name(s) Surname                 

Current Institution/University Position & department           

PhD title:      

Year PhD commenced

Year PhD was or isexpected to be completed

Life Sciences Physical Sciences            

Title Proposed start date (if known)           

Proposed destination(s) Duration at destination(s)1

           

Organisation(s) you’re planning to visit                 

I also wish to apply for an AFAS Associate Award No

Postal address (must remain current until 31 December 2018)

Address line 1 Address line 2           

Suburb State Postcode Country                       

Email (must be accessible until 31 December 2018)     

Phone (home) Phone (work) Phone (mobile)

                 

I have attached legally certified2 evidence of my Australian or New Zealand Citizenship3, or Australian permanent residency No

1Study missions should be short-term. They are to assist in developing a commercial idea; undertake specialist training; or career development not available in Australia. Fellows are required to return to Australia on completion of the Study Mission.2Information on Authorised persons able to certify documents can be found at; http://www.justice.vic.gov.au/home/justice+system/legal+assistance/justice+of+the+peace/3 Australian citizen, or a person who forfeited their Australian citizenship on the acquisition of another citizenship before 4 April 2002 under the now repealed Section 17 of the Australian Citizenship Act 1948, or a person who was forced to renounce their Australian citizenship under Section 18 of the Australian Citizenship Act 1948 in order to retain another citizenship or acquire another citizenship. Applicants who are not currently Australian citizens will be required to provide evidence with their applications that they have previously held Australian citizenship.

Please provide details of the two referees4 providing written support for your application

Referee 1: Name (title, first name, last name) Position/Organisation

           

Address     

Email     

Phone Mobile

           

Referee 2: Name (title, first name, last name) Organisation           

Address     

Email       Phone       Mobile      

I have advised my referees to submit a referee report 4Referees should be able to assess your application. International referees and referees outside the applicants organisation or department are strongly encouraged.

Head of organisation or departmentName Position

           

Organisation     

Address     

Email     

Phone Mobile           

I, TYPE FULL NAME HERE confirm all information provided above is true, and agree that as a condition of my forwarding this application, I permit the release of all materials that I have submitted to third parties for the purposes of the selection process.

Please check box as confirmation Date      

No

Host organisation veski website veski bulletin

Referral Please specify       Other Please specify      

Statement of consentI, TYPE FULL NAME HERE have read the Application Guide for the Victoria Fellowships and confirm that the information contained in my application is true and accurate. I agree that, as a condition of my forwarding this application, I permit the release of all materials that I have submitted for the purpose of the selection process. Furthermore, I understand that in the event of an award of a Victoria Fellowship, a description of my research project will be publicised.

Please check box as confirmation Date