SEKRETAfuAT JENDERAL - Bagian Kepegawaian

KEン 2NTERIAN
ttLAUTAN DAN PERIKANAN
SEKRETAfuAT JENDERAL
NOTA DINAS
,n
Y
Yth.
Nomor:$2$ i SJ.7 / KS.12O tVl t 2015
Sekretaris
Sekretaris
3. Sekretaris
4. Sekretaris
Ditjen
Ditjen
Ditjen
Ditjen
Perikanan Tangkap
Perikanan Budidaya
Pengolahan dan Pemasaran Hasil perikanan
Kelautan, Pesisir, dan Pulau-pulau Kecil
5.
Sekretaris Di$en Pengawasan Sumber Daya Kelautan dan
6.
Sekretaris Badan Penelitian dan Pengembangan Kelautan dan
7.
Sekretaris Badan Pengembangan Sumber Daya Manusia dan
Perikanan
Perikanan
Perikanan
B. Sekretaris Badan Karantina lkan, pengendalian Mutu, dan
Keamanan Hasil Perikanan
Sekretaris lnspektorat Jenderal
10. Kepala Biro Kepegawaian
1 1. Kepala Biro Hukum dan Organisasi
12. Kepala Sekretariat Dewan Kelautan I ndonesia
Kepala Pusat Analisis Kerja Sama lnternasional dan Antarlembaga
Segera
9.
ｉ
ｒは ｌ
ａ
ａ
ＤＳＨ
Lampiran
Tanggal
Permohonan Penyampaian Usulan Calon peserta Australia
Awards Scholarship (AAS) Tahun 201512016
:
:
Satu Berkas
Juni 2015
3
Merujuk Nota Dinas kami terdahulu Nomor: 666/sJ.7ilvt2o1s tanggal 28 April
berikut--
20'15, dengan hormat kami menyampaikan beberapa hal sebagai
1.
Australia Awards scholarship (MS) telah membuka pendaftaran bagi calon
pelamar beasiswa program S-2 (Mastefi dan 53 (Docfor of philosophy) dengan
berbagai program bidang studi.
2.
Beasiswa AAS terbuka bagi seluruh pegawai negeri sipil lingkup KKp yang
memenuhi kriteria umum sebagai berikut:
a) Usia maksimum 42 tahun
b) Masa kerja minimum 3 (tiga) tahun
c) IPK minimum 2,75
d) Kandidat Master, minimal nilai IELTS S,O, paper-based TOEFL minimal S00
atau internet-based TOEFL minimal 59, yang diperoleh minimal pada tahun
2014.
e) Kandidat 53, minimal nilai IELTS minimal 6,0 atau paper-based TOEFL minimal
550 atau internelbased TOEFL minimal 79, yang diperoleh minimal pada tahun
2014.
Untuk pelamar 53 yang pernah mengambil program 52 melalui beasiswa
Australia Awards, harus tinggal dan bekerja di lndonesia selama dua kali masa
studi sebelumnya, terhitung sejak tanggal kembali ke lndonesia.
f)
Persyaratan lain untuk mendaftar mengacu pada formulir aplikasi beasiswa
sebagaimana terlampir.
,,
3. Berkenaan dengan hal tersebut, kami mohon bantuannya untuk dapat
menyampaikan usulan nama pejabaUstaf yang dinominasikan sebagai calon
peserta selesi beasiswa AAS kepada Pusat Analisis Kerja Sama lnternasional dan
Antarlembaga selambatnya tanggal '19 Juni 2015. pernyampaian usulan dimaksud
dilampiri formulir aplikasi beasiswa yang telah diisi secara lengkap dan dilengkapi
dengan seluruh dokumen yang dipersyaratkan.
Atas perhatian dan kerja samanya, kami mengucapkan terima kasih.
咆
Anang Noegroho
Tembusan:
Sekretaris Jenderal
KEMENTER:AN KELAUTAN DAN PER!KANAN
SEKREttARIAttJENDERAL
NOTA DINAS
Nomoc
Yth.
:
ｍ ｌ
．
ａ
助 Ｈ
Lampiran
Tanggal
@5/sa?
NfAs
Sekretaris lnspektorat Jenderal
2. Seketaris Direktorat Jenderal perikanan Tangkap
3. Seketaris Oireklorat Jenderal perikanan Budidava
4. Sekretaris Oirektorat Jenderal pengolahan dan'pemasaran
Hasll Pedkanan
5. Seketaris Direktorat Jenderal Kelautan, pesisir dan pulauPulau Kecil
6. Sekretaris DreKorat Jenderal p€ngawasan Sumber Daya
Kelautan dan Perikanan
7. Sekretaris Badan Peneli an .dan pengembangan Kelautan
dan P€rikanan
8. Sekrotaris. Badan p€ngembarEan Sumber Daya Manusla
,Glautan dan Perikanan
9. Sekretarls Badan lcrantina lkan, pengendalian Mutu dan
Keamanan Hasil perikanan
10. Kepala Biro lGpegawalan, Sekretariat Jenderal
11. Kepala Sekretariat Dewan Kelautan lndonesia
lcpala Pusat Analisb Kerja Bama lntemasional dan
Antarlembaga
Pondaftaran Austnlla AwE ds Scrorarsrrrp (AAS) Tahun
2015t2016
Satu berkas
April 2015
'1.
e,
Sehubungan dengan surat Taryetecl Organiseuons and sector Manager
Atdnlian Awads Schotarstp (MS) tanggat 23 Aprit e015
{)
{saflnan
terlampir), bersama inl kaml menyampaikan bahwa pendaftaran AAS akan
dibuka padatanggal '18 tdei2015 dan ditutup pada tanggal 31 Juli2015.
Berkenaan dengan hal blsebut, kaml mengfiarapkan bantuan Saudara
unfuk kiranya menyampaikan informasl awal lnl t€pada peJabaustaf di
lingkungan unit kerja Es. I maslng-maslng. lGmi akan rnenyampaikan jad$/al
tahapan dan percyaratan proces seleksl pada kesempatan pertama.
Perlu kaml lnformaslkan pula bahwa berkenaan kebflakan ,6afu pintu,
MS
untuk penyampalan usulan calon peserta rnelalul pusat Analisis Kerja
Sama lnbmasional dan Antarlembaga, maka apllkasl yang hngsung
dlldrimkan kepada AAS tidak akan diproses leblh lanjut
Atas peenan dan tthanttЫ h bり 鳴 kemi mengucapkan tenma・ kash.
鳳
Anang Noegroho
Tembusan:
Seketiaris Jenderal (€ebagai laporan)
Australia Awards Scholarships Application
2016 1ntake
AustmliaAwsrds
Instructions
Please print neatlv in this application
Before completing this form, you must read the Australia Awards Scholarships Policy Handbook (Handbook) and your Country's (or
Regional) profile, available on the Department of Foreign Affairs and Trade (DFAT) website (see Useful websites on page 6) or from
the Australia Awards office in lndonesia. Applicants also are encouraged to review all information available on the Australia Awards
Scholarships
>
>
>
>
-
lndonesia website (www.australiaawardsindonesia.org)
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 31 Juty 2015 at the Australia Awards Office at
Gedung Wirausaha, 7th Floor. Jl. H.R. Rasuna Said Kav.C-S 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 lndonesia. A list of the priorities is available under 'Choosing a Course of Study" on page 3 of this application form.
DFAT's website includes a list of Australian Universities that may receive Australia Awards Scholarship recipients. Course of
study information is available directly from the Universities'websites or the Commonwealth Register of lnstitutions 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.
lf 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 the Handbook. Please note that DFAT reserves the right
to change these conditions.
lf you do not receive an invitation to an interview from the Australia Awards office by mid-December 2015, you should assume
that your application has been unsuccessful.
Applicants must not fill in section 23 of the application form. This section is for use by the Ministry of State Secretariat of
Republic of lndonesia (KemenSetNeg) and refers only to selected candidates.
ln cases where information supplied by candidates is found to be inaccurate or incorrect, an award offer may be revoked
notice.
The closing date is 31 July 2015
Applications should be submitted as early as possible
Ceneral Infomation Notes
'Australia Awards'scholarships are an importanl component of Australia's investmenl in education. ln lndonesia, Australia Awards
Scholarships provide opportunities to study in Australia at Postgraduate level. They are provided to lndonesian citizens to provide
enhanced leadership, knowledge and technical skills to the Governmenl of lndonesia, to tertiary institutions and to strategic
organisations that are driving sustainable development.
Australia Awards Scholarships have been an important componenl of the Australian Government's efforts lo reduce poverty and
achieve sustainable development since the 1950s. This is achieved lhrough:
. developing capacity and leadership skills so that individuals can contribute to development in lndonesia;
. building peoplelo-people linkages at individual, institutional and national levels between lndonesia and Australia.
There are a number of supplementary programs associated with Australia Awards Scholarshlps in lndonesia including the Australia
Awards Leadership Program and the Allison Sudradjat Prize.
Public applicants are from government organisations, state universities and state owned enterprises and must be approved by
training or foreign cooperation bureaus (BKLN) of their local or central agencies (see page 26). Public applicants from government
agencies outside Jakarta may apply directly to the Australia Awards Scholarships program office with the approval of their relevant
Kakanwil or Kadinas and approval from Bupati or Governor (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 of support from the
applicant's home agency, institution or private university may be included with the application. Public servants (pegawai negeri)
cannot apply as'open applicants'.
Targeted and Non-Targeted Category
Australia Awards Scholarships are awarded as 'Targeted' or 'Non-Targeted'. Up to 70% of Australia Awards Scholarships are
Targeted; available for nominated staff ftom Government of lndonesia Priority Organisations, Targeted Sectors and from DFAT
Geographic Focus Areas. Further information on each of these sub-calegories is available at www.australiaawardsindonesia.org
At least 30% of Australia Awards Scholarships are Non-Targeted available for public servants and non-public servants outside the
DFAT Geographic Focus Areas.
Scholarships are for full-time study for a Masters or Ooctorate degree from Australian tertiary institutions. The scholarship provides
up to nine months full-time language and academic preparation in lndonesia. Students must achieve satisfactory results in this
training to be able to continue their scholarships.
Social inclusion
Eligible candidates with a disability or from organisations working with the disabled are encouraged to
apply. Women
and
candidates within DFAT Geographic Focus Areas' are also encouraged to apply.
Eligibility
ln general candidates must:
>
>
be an lndonesian citizen and be residing in and applying for the scholarship ftom lndonesia
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 ofthe application, selection, mobilisation processes orwhile on-scholarship in Australia
>
>
>
satisfy Australian Govemment 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{erm Australia Award unless lhey have resided outside Australia for twice the length ot the lotal
time that they were in Australia (for example, a previous Ausfalia 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 lndonesia
for eight years)
>
>
>
>
have satisfied any specific criteria established by lndonesia or government of lndonesia
nol be current serving military personnel
be able to satisfy all requirements of the Deparlment of lmmigration and Border Protection (DIBP) for a OFAT studenl visa and
be able to satisry the admission requirements of lhe Auslralian university at which the Scholarship is to be undertaken.
Aceh, Nusa TenggaraTihur, Nuss Tenggara Barat, Pspua. West P6pua
Specifically, candidates must:
>
>
>
of
be applying fcir courses that fall within the areas
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 Targeted Category
including DFAT Geographic Focus Areas and for applicants with a disability as declared on the Australia Awards Scholarships
application form)
>
For Masters applicants - have an English language proficiency of at least 5.0 in IELTS (or 500 in paper-based TOEFL or 59 in
internet based TOEFL or PTE Academic equivalent). For PhD applicants - have an English language proficiency of at least 6.0
in IELTS (or 550 in paper-based TOEFL or 79 in internet based TOEFL or PTE Academic equivalent). The IELTS or TOEFL or
PTE Academic result must be currenl (a test result obtained in 2014 or 2015 will be considered current. No other English
language test (including TOEFL prediction test) results will be accepted.
>
>
>
already hold an undergraduate degree, if applying for a Masters
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 Australian Government activities
>
it is highly desirable for Doctorate applicants to have a letter of support from an Australian university for their proposed fleld of
study, and for PhD applicants to have completed a Masters with a minimum 25o/o research component
>
>
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
lndonesia 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 Priority Development Areas (PDA). The PDA relate directly
to the strategic objectives contained in the Australia and lndonesia Country Strategy. An indicative list of the areas for study follows.
Priority
Development
Areas (PDA)
Description of PDA
Sustainab:e Growth and
Democracy Justice and
Economic Management
Good Governance
lmproving economic policy
and management, reducing
Strengthening the
capacity, a@ountabilw
and responsiueness of
legal, democratic and
oversight institutions, and
improving local
govemment and public
financial management.
Better quality, access and
govemance in education,
and better health access
and syslems
.
o
.
o
.
.
o
o
.
consfrarnts to grovtth in
infrastructure and
productivity, and improving
natural resource
man agement, environmental
governance and response to
climate change.
P面 onty Fie!ds of
Study
N8: ″yotrrsttrψ area
o
Natural Resource
Management
o
.
.
.
.
.
o
.
.
o
o
.
rs,ο
Mining
Livestock management
Animal Husbandry
Agriculture
Aquaculture/fisheries
Forestry
Climate Change
Economics
lnfrastructurePlanning
Water and Sanitation
Rural Growth
Small and medium
enterprise
:″ sよ
lndonθ Ja ParfnersfllP CO●
ガ カec y● ●may
′″y
o
.
o
.
e
.
.
o
Law, legal and
judicial systems
Political Science and
Government
Publicadministration
Public expenditure
management
Public Sec{or Reform
Environmental Law
Anti-corruption
Decentralisation
Monitoring &
Evaluation
stll appry fora feld o「
sf● dy
Stralegy ar力 rfpiた fddralg。 ′a“ √υわ
たa″
Fraled f●
lnvestlng in People
.
r
o
Safety and Peace
Communicable
Disease Prevention
Health Management
Health Services
Maternal and Child
Health
Women and Gender
Studies
Disability Services
Public Health
Education and
Training
lmproving responses lo
humanitaian needs,
emergencies and
v u lne rabi lity to disaslers,
and improving capacity to
ensure transpoft security
and to counter threats from
transnational cime.
.
.
.
.
.
o
Conflict Resolution
Disaster Prevention
and Management
Transport Safety
Transnational Crime
Prevention
Development Studies
lnternationalStudies
Education
Management
Human Resource
Childhood Special
Education
詢ew● 慮 o「 DFAT h frldoneJa Fo″ mo″ hromaJ。 ,seeめ eA● sfra″ a
oanc″ menfs/arp
straL2008‐
f〔
J
Lengllsh ρ
Candidates considering study for particular professlons should note that Austra!ia Awards Scholarships does not include the
practica!training period required for professlonal registration,e.g.rnedical internships,:egal articles etc Successful reciplents are
expected to complete such training in their own country.
R
Selection Process
All applicants are considered by an independent Joint Selection Committee comprised of Australian and lndonesian 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 lndonesia. 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 DFAT and Government of lndonesia
-
Ministry of Stale 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 DFAT
Geographic Focus Areas
>
>
At least 30% of awards Wll be offered to applicants from the Non-Targeted Category,
85% of awards at Masters leveland upto 15%of awardsat 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 organazations
associaied with Australian Government activities).
>
an equal number ofawards will be offered to men and women.
Notification of the selectlon result
All applicants will be advised whether or not they have been seleded for an inlerview. All interviewed applicants will be notified
whether or not they have been awarded an Australia Awards Scholarships. The result is linal and no correspondence will be
entered into. Where appropriate, notification will include details of pre-deparlure training (English, academic skills, cultural
preparation). This training is compulsory and tull-time (see page 6 for step by step of Australia Awards Scholarships Application
Process).
Pre-Departure English for Academic Purposes (EAP) Training
DFAT will provide all scholarship recipients with EAP training in lndonesia. The aim of EAP training is to prepare students for study
in Australia. The length of EAP training will range from 6 weeks to 9 months depending on the level of English language proficiency
of the student. EAP training is conducted in Bali for students from Eastern lndonesia and Jakarta Ior students from western
provinces.
EAP trainino is compulsorv and full-time for all Australia Awards ScholarshiDs recioients.
DFAT will provide recipients with a monthly living allowance from the commencement of EAP training to end May (Semester 2
commencement in Australia) or end December (Semester 1 commencement in Australia). This will not apply to a deferral period
after EAP.
DFAT, through the Australia Awards office, may consider, on a case-by-case basis, waiving attendance at EAP training, but waivers
are rare and strict criteria apply. DFAT will not provide additional EAP training in Australia.
Recipients who withdraw from Auslralia Awards Scholarships afrer commencing EAP training, may be required to refund the
stipend paid lo the recipient from the commencement of EAP. Circumstances for withdrawal will be reviewed on a case by case
basis.
Requirements fbr Scholarship Recipients
Prior to travelling to Australia, scholarship recipients muat:
>
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 compleiion of EAP training, candidates must achieve a minimum score of IELTS 6.0 for Australia Awards Scholarships
offlce to commenc€ the application proc€ss for placement in a university program in Australia
>
>
>
meet Australian immigration requirements for a student visa
receive Government of lndonesia endorsement
be medically fit to commence studies in Australia.
ln 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 DFAT, or to any Australian university or to lndonesia
ln addition, scholarship recipients must
>
gain support from DFAT if seeking to return to Australia within the two-year exclusion period for anything other than a short term
visa for up to three months. Visa applications for short-term visits do not require DFAT's approval
>
return to lndonesia for a period equivalent of twice the length of the study period in Australia, before re-entering Australia on
another Government of Australia funded scholarship
>
if during the two years exclusion period the scholarship recipients return to Australia, a debt to the Commonwealth may be
activated OR any time spent in Australia may be added to the two year exclusion period.
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-lndonesia stipend)
>
ln-lndonesia 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
DFAT Student Visa and Student Dependant Visa
Outward Airfare (economy- one way) from the airpo( closest to the recipient's 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 recipient's bank account after arrival in Australia
Contribution to Living Expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses (CLE).
lntroductory Academic Program (lAP) 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
Supptementary 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 lndonesia 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 Australia Awards 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 recipient's home location.
Family Entry
Recipients can bring their immediate families to Australia
at their own cost, if their families meet DFAT and
requirements. Families are normally permitted to join eight (8) weeks after the recipient's arrival.
immigration
Useful websites
Australia Awards : htto://a ustraliaawards. qov.a u/
Australia Awards Scholarship lndonesia: htto://www.australiaawardsindonesia.oro
DFAT: htto://aid.dfat.qov.aula ustralia-awards
Visas
-
Department of lmmigration and Border Protection: htto://www.immi.qov.au
Studying in Australia: http://www.studvinaustralia.oov.au
CRICOS: http://cricos.deewr.qov.au
IELTS : http://www. ielts.oro
TOEFL: http://www.ets.oro/toefl
PEARSON: htto://www. pearsonpte.com
The Australia Awards Scholarships
Application Process
Step 1
Applicant sends complete Australia
Awards Scholarships application
form to Australia Awards Office by
3'l July 2015.
Step 2
Applicant is notified of the result of
selection for interview by
mid-December 2016.
Step 3
Applicant selected for
interview receives
information of intervieW
IELTS test date/location.
Step 4
Applicant attends
interview and IELTS test in
January 2015.
Step 5
Applicant is advised of
the result of their Australia Awards
Scholarships application by
February 2016.
じ雲 曇等
彗瞥
Aus懺 滅iaAwards
l.
Australia Awards Scholarships Application
2016 1ntake
Personal details*
ｒ ｅ
Ｍ ｈ
ｔ ．
０ ・
Ti‖ et
D
Mrs
一
(Please specify)
l Family name★
Given names*
I I
Date of birth.
l_l
Gender*
i COuntry of
i CliZenship☆
dd/mm/yyyy
Male
Place of birth'
(State/provilce)
LJ Female
i
:
Note: You must be a citizen of one of the eligible participating countries.
, Do you have dualcitizenship?.
:
￨□
Yes
□ No
2nd country of citizenship
Note: lf you are a citizen of Cook lslands, Niue or Tokelau and are entitled to hold a New Zealand passport, please do
list New Zealand as your first or second country of Citizenship.
Which country are you living in now?*
Have you applied, or are you intending to apply, for
permanent residency or citizenship in Australia or
New Zealand?*
￨□ Yes
□ No
National ldentity Number
' Note: Provide if applicable to your country.'
Passport no.
(provide if you have a passport)."
date I
Expiry date I
lssue
g.!
2. Contact details*
…
Address
line 1*
Address line 2
Address line 3
Postal code (if any)
Town/City'
State/Province*
Country*
Address line l・
:
Address line 2
:
Address line 3
Postal code (if any)
State′ Provincet
i
Address line l・
2
Address line 3
:' "*---*'-'
Town/City'
Address line
;
:
:
'-t--:
Postal code (if any)
.
Country*
Mobile no.'
Primary Email'
Work phone no.
︰
一
一
︱
Fax no. (if any)
‘ ︱
︱
︱
Alternate Email
Not applicable
□
Family name*
Given names*
Note: Provide family name and other names as they appear in your spouse's birth certificate, passport or other official
identifi cation document'
Date of birth★
ノ
□ Fema!e
I Gendert E]Ma!e
dd/mm/yyyy
ノ
(Provide if spouse
, has a passport-)
llSSue date
/
I Expiry date
/
′
ノ
Country of
citizenship.
Will your spouse accompany you to Australia?*
￨□
4. Chitdren details (attach a seDarate list if there
Yes
□ No
is not
I Child l
l Family name★
Given names*
birth*
Passport no.
Date of
(PrOVide r child has a
:, I
/
-t-
,
I Expirydate
l paSSport★ )
1猟
せ
Wλ 電
!Fmpany□ Y∝
:よ
n uate I
I
i lssue date t
dd/mm/yyyy I Gender.
□ No
ノ
ノ
Female
4.Children details(continued)
Child 2
IFam‖ y
,
namet
i
Given namesr
￨
Date of bitth★
;;;;r' n rr,"
dd/mm/yyyy
ノ
lssue date
Passport no.
(PrOVide if ch‖
flFemale
d has a
PaS｀ Pυ :t′
1
1
謂
‖ ほ
￨
￨ヒ
治S
mpany l□
1猟 Wλ :よ
Xp:rγ
oale
′
′
□No
I Child 3
,
Family name*
:
Given names*
Date of birth"
ノ
/
nFemale
′
lssue
ノ
I Expiry date
Will this child accompany
you to Australia?*
1 Fami!y name・
ノ
date
Passport no.
: (Provide if child has a
passport*)
I Child 4
Gender'nUate
dd/mm/yyyy
flves
ノ
□ No
,
1
Given names*
打
Date of birth*
dd/mm/yyyy
￨ノ
;Gendef
ノ
da.te
Passport no.
(Provide if child has a
passport.)
f]Female
ノ
lssue
′
Expiry date
′
□ 一
Will this child accompany
you to Australia?.
fl tvtate
Yes
:Child 5
IIFIIIIIII■
:譜繋
■___
聯壺ⅢF● TIIⅢ lr
ギTt三 ‐
/111111ttIII西 亜
IⅢl●IIIl「
鵠
l剛
￨
passport*) … i
,
VVi‖
:
this child accompany
you to Australia?'
I
I
ves
Expiry date
ノ
′
contact details*
￨□
Mr
□ Ms
□ Mrs
□ Mも s
□
Dr
□ Other(PleaSe specry)
name*
Family
Relationship to you*
l
.
Given
name*
,
.
Gender.
f]trlate
I
Female
￨
′
you *
Home phone'
I WOrk phone
: Fax (if any)
. Mobile phone
I Emai!1
1 Emali 2
I Address line l
Address line 2
Address:ine 3
Town/City
, Postal code (if any)
State/Province
Country
Note: Please check that the contact details are conect
6. Previous scholarshi
attach a
rate list if there is not
Have you previously been awarded a scholarship or a
fellowship?*
￨□ Yes
l. Scholarship/fellowship title
′
:lnstitution
:
′
End date
l
12.Scholarship/fe1lowsllip title
Start date
:Qua‖ lcatlon
l(if applicable)
:nstitution
: Country
′
7. Scholarshi
ications
I ves E tlo
lf 'Yes', how many times have you previously applied and in which years did you apply? (approximately 100
words limit):
I Yes E tlo
lf 'Yes', in which years?
,DPuutic
nopen
, lf 'Public", please indicate if your application is from:
lf 'Open', please indicate if your application is from:
n
tr
D
n
n
n
Governmentdepartment
State-ownedenterprise
State university
study*
Doctorate studies? (Recommended)
flYes
D
No
Private university
Private organisation
Private individual
fleld of stud
Priority
:n
n
',
lmproving economic polby :Strengめ enわ gめ e
PDA
',
and management,
i capaCity,accoυ ′rabll掟y
, and resρ OrDslve″ ess Of
i legat demο C● rlc and
i
:,
Better quality, access and
: govemance in education,
I and better healf/r access
i and systems
οveslgb′ ゎsflfυ ons,and
l hρ rOЙ ng roca′
management,
l gOVe177menr andρ υOた
,,
lmproving responses to
: humanitarian needs,
emergencies and
v u I n e r a b i I ity to disaslers,
I and improving capacity to
: ensure transpott security
r′
improvi ng n atu ral re sou rce
environmental g ove m ance
to climate
□
□
Description of
, reducing constraints to
g rov,tth in infrastructu re
, and productivity, and
!nvesting in Peop:e i Safety and Peace
Democracy Justice
and Good
Governance
Sustainable Growth
Development and Economic
'
Areas (PDA)* ' Management
:
I and to counter threats from
: tnnsnational cime.
i
￨″ nanCialmar7agemenr
' and response
: change.
Priority Fieids
￨□ Natural Resource
of Study
l
(PFS)・
i□ Mhing
n
Management
!
i[コ Livestock
l
management
D
l□ A雨 mJ Husbandり
￨□ AgHcunure
,□ AquacuLureノ
1
lsheries
l□ Forestry
l□ Climate change
,□ E∞ nomics
l□ lnfrastructure
,
Planning
i□ Water and
I
Sanitation
l□ Rural Gromh
E
I
uw,legaland
:□ CommumcaЫ e
judicial systems
l
PoliticalScience
and Government
l□ Heanh seⅣ ices
IE]Conlict Resolulon
Disease Prevention
i□ Disaster Prevention
l□ Heanh Management i and Management
□ Transport SaFety
Public
administration
l□ Maternal and Chi同
l□ Transnalona!C‖ me
I
I
Public expenditure
l□ Women and Cender iE]Develolment Studies
management
i
Public Sector
Reform
l□ Dに aЫ 1ly Services
! Environmental Law
fl Anti-corruption
E Decentralisation
! Monitoring &
Evaluation
Health
Studies
‐
□ PubliC
Prevention
l[コ internationai Studies
Health
i□ Educalon and
l
丁raining
l□ Educaloo
l
Management
l□ Human Resource
:E]ChildhoOd Special
l
Education
:□ Smdland medum
l
n
enterprise
Other, please specify,
Have you obtained information from the Australia Awards Scholarships lnformation
CD, oi from the Australia Awards Scholarships website regarding study options in
!
Yes
Australia?.
Please describe the efforts you have undertaken so far to obtain information on your study options in
Australia.
□
No
Prefere,nce
1
CRICOS code.
Course title*
, lnstitution"
: lnstitution's minimum
:
Course duration
(weeks)*
:
Preference 2
English language
profi ciency required for
, the course (lELTS,
TOEFL or Pearson)*
,
CRICOS code.
,
Course title'
Course duration
(weeks)*
￨
l institution★
: lnstitution's minimum
I English language
i proficiency required for
r the course (IELTS,
I TOEFL or Pearson)*
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. lf "Yes", please aftach
any relevant correspondence with Australlan universities
Arethereanyspecialsubjectsorskillsthatyouwouldlike
to include in your choice?
n
Yes
trNo
n
Yes
nNo
l
lf "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).
Research pro
detalis
research a
licants onl
Not applicable
Research title (approximately 30-50 words limit).
Objectives lappioximitety f SO-ZOO worOs timitl.
signiiicince ano poitiute
(approximately
1
,tpiiliion oifoui
piopoJeo researcrr to your country's development
50-200 words limit)*
Proposed research method (approximately 150-200 words limit)t
, Does your proposed research include fieldwork?* r
n Yes
n ruo '
f] Not sure
lf 'Yes' please provide a description of the fieldwork you will be undertaking (approximately 200 words limit).
What is the duration of your
fieldwork? (if known)
proposed '
Proposed supervisor/s
fieldwork?
,
weeks
alifications*
1. Qualification name
Level of study*
!
Secondary (High School)
!
Vocational/tech nical
!
Undergraduate
E
Postgraduate
(S2E
or
S3fl)
Name of institution*
State/Province
Language of
i COuntry'
instruction
:Obtained
GPA ff appliCable)
i start date'
ノ
ノ
:End date ・
ノ
ノ
.
ノMax
￨
Statust
2. Qualification
I
.
I
Complete
,
U
Secondary (High School)
Pending results
!
lncomplete
name
:_
, Level of study
□ Vocalonattech面 cal
□ Postgmduate(S2□ or S3□ )
LJ Undergraduate
Name of institution
lcω tty
State/Province
￨
I Language ofinstruction
l
…
GPA〔 f
:
I Start date
… ― ￨… 一 ―― 一一一 刊 一 一
appliCable)
:Status
1 0btained
i
/Max
fl
flComplete
I End date
Pending results
ノ
′
ノ
′
!
lncomplete
13.QualincatiOn name l
,
:Level of study
.
r
Name of institution
:
State/Province
E
Secondary (High School)
fl
Vocational/technical
!
Undergraduate
!
Postgraduate
:
or
S3n)
Country
Language of instruction
GPA(r applicable)
(S2U
1 0btained
ノMax
i Start date
′
′
I End date
ノ
ノ
￨
E
Complete
I
Pending results
E
lncomplete
detailst
!s English your first language?
E
Yes
E
Yes
□ No
flYes
□ No
lf 'Yes' go to next section. lf 'No' answer the following questions:
Was English the language of your highest level of study?
lf 'Yes', provide a statement from the institution verifying the language of instruction.
I HaVe you taken an iELTS,TOttFL or PTE Acadenlic?
l lf｀
Yes',provide the test results.
Test name (lELTS,
TOEFL or PTE
Academic)
Date test
taken
Test Centre/location
Phone
,
Overall
: SCOfe
I VVebsite l
Writing Score
Reading Score
tt
Speaking Score
Listening Score
lf 'No', when do you
expect to complete
the test?
Test Name
ノ
ノ
Are you computer literate?
E
How regularly do you use a PC/computer?
Yes
￨□ MOnt‖ y
n oaity
l□ Weetty
!
Occasionally
' Do you have experience with the following software?
LWdlじ
U｀ 9 ftware
i□ YeS
WYlll17:gng
S°
瑞 群 :;ギ
:□
)ジ
FFWare
(e,9, 営△
AcceL)?
Yes
l□
'-.-
‐濁
ij"^'"jl:il":sotryare
:口
.(eg.POWerPoht)?
internet browsers(e.g.
l internet Exploreり
I ves
:し 。
l□
Yes
u twdlo
No y」
lシ r智 奮,SOflWare
□No
じ
□
視
No
□
LJ "-
l警
(e:g
`｀
□
Yes
u Yes
黒翠 2000)?
、
っ ￨□
Windorrus TRハ
=認
VI(e.g.Ou‖
E No
口
野
:sif:ly3l:
ook)?
1口
i StauSucal packages(e.g.
□ No
ab)
iSPSS Or Min‖
! yes
'ν 。
‐
□ Yes
□
No
□No
n
口
ruo
V
:｀
□ No
1■ C91■ pl1191 11a“ 1■ g,J9111lS
￨□
Not applicable
Course name
1
Start date
Course name
ノ
ノ
I End date
ノ
′
I End date
￨
′
ノ
2
・
・
１
１
Start date
１
一
14. Current
Are you curren‖
yempb"d Yes□ No□
lf 'Yes', please provide details below
I Position title
1 0rganisalon name
1 0rganisation address
l Levd ofpos蘭
on h
i
「
i
1 0rganisation structure
ノ
:
l
i
Sector/organisation type
'
ノ
IDatecommenced
reg.Ec′ ]eron ard GOrongaり :
E
GovernmenUpublic
E
NGO /civil society
!
Private
I Current duties and
l reSpOnsibilities
(apprOXimately 80‐ 100 words
iiml)
Do you intend to return to this organisation after your scholarship in
:Australia?★
￨・
￨□ Yes
Denotes mandatory fie:d
￨!f`Yes'lhow wi!lthis scholarship contribute to the organisation's human resource development needs?
(apprOXimately 80‐ 100 words‖ ml)
lf 'No', what are your plans when you finish your studies? (approximately 80-100 words limit)
□ No
1
5.,Previous relevant em
I.
Previous position
Position tlle
Organisation name
Organisation address
1 /
Start date
,
ノ
End date
ノ
ノ
ノ
ノ
Duties/responsibilities (approximately 80-1 00 words limit)
2. Previous position
I Position tltle
l
1 0rganisalon name
l
Organisation address
:
Start date
￨
ノ
ノ
I End date
:
Duties/responsibilities (approximately 80-1 00 words limit)
￨
statement'!
1. How did you choose your proposed course and institution?*
2. How will the proposed study contribute to your career?*
3. How have you contributed to solving a challenge and to implementing change or reform?*
(Be specific and include: what aspecUs of your leadership knowledge, skills and practice you consider to be
well established and effective; which people or organisations you worked with to solve the problem; and what
creative methods were used.)
1,1
‐
4.
'llppo「 ting,tatel■ 911(COntil1191)す
Please
a) give up to three practical and realistic examples of how you intend
to use the knowledge,
skills and connections you will gain from your scholarship. Possible tasks can be personal
and/or professional; and*
b) list any possible constraints you think may prevent you from achieving these tasks.*
5. Please indicate the development theme that is
q!
relevant to your application, even though it may
be relevant to more than one.*
n
f]
Disability
Disaster risk reduction
IE]HeaLh:HiVノ AIDS:pandemics
I
Economic growth
l□ Agnculure and ishe‖ es
D
Education
l□ lnfrastrudure
!
!
Environment
ty
l□ Regbnd staЫ ‖
food security
:□ Ruml devebphent
n Gender equality
l□ Water&sankalon
f]Governance
6. Do you currently have any connection or relationship to any
staff employed at DFAT Posts or with DFAT's
contractors?*
managing
,
I yes
E
〔
コYes
□ No
No
* Denotes mandatory field
lf 'Yes' please specify.
:7。
Are you subieCttO any criminal or civ:l proceedings that are l
l Curren‖ y awaiting:egal ac● on?★
l☆ Denotes mandatory“ eld
lf｀
Yes'pに ase ex口 a!n.:nfOrmalon prouded here will not necessa‖
ly dに qua‖ fy
you■ om being∞ nsdered for
a scholarship
Lirnit your answers to 330-400 words. Attach a page ifnot enough room on this form P:ease note word
:irnits. Anything over this linlit vvi‖
not be considered.
□ No
DFAT 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 adjustnrents' 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, awardees
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 lnstitution's capacity. DFAT will
advise the lnstitution of any special requirements associated with an Awardee so that the lnstitution can pass
these details to the lnstitution's Disability Liaison Officer prior to the Awardee arriving on-campus. Where an
lnstitution is not able to provide the assistance requested, other lnstitutions may be recommended.
lf yes, please provide details if you require special assistance or equipment to participate in the scholarship
selection processes or to live and undertake studies in Australia?
I
7. Professional membershi
1. Organisation Name
I Highest position held(if any) :
‐Start date
:
, Oro,nie,linll N,mp
′
ノ
I End date
l
ノ
i
Highest position held (if any)
:,t,11,ヤ
_
_ill l_ … …_三 11,ate
:
ノ
:Highest pOsition he:d(if any) :
Start date
ノ
′
I End date
:
′
ノ
Communication*
□
D
DFAT Scholarship recipient
一
□
卜‐
i Friend, relative or colleague
□
Alumni Association
n
Australian Embassy
I
□13111lξ )Awards()価 cO
Australia Awards rvebsite
,:
[
‖
a Awards Promolond
:一
□サ
:賄
□10[誕 ilaAwads:ndoneda
1倉
,
D
' Home institution or university
Workplace or nominating
authority
Publication, radio, TV (specify
Tl
Australian institution or
university (specify below)
below)
□ Other
鋪∝
□箇翡知訂
“
□1継誕iPAwardsindonesb
n
Friend, relative or colleague
n
Education Agent (specify)
' and Trade (DFAT) Office
i Government of Australia , Department of Education (DoE) .
[
Government of lndonesia State Secretariat Office
D
詰
薔
:鳳1鏑
Office
DFAT project office
1lit:亀
(specify)
1占
:占
':'
:
f]
-
, Government of Australia
I Department of Foreign Affairs
Australia Awards ScholarshiPs
Workplace or nominating
authority (specify)
キ
1
1 _
__ _____…
1 0ther(specify)
, information CD-ROM
‐1-一
￨
1
‐i_
__ ___ __ _
‐
‐
´
‐
19. Intervierv location*
`● It・
ill‐
fl
I
I
!
D
I
.tatarta
Yogyakarta
Surabaya
Denpasar
BandaAceh
tr'ledan
I
!
E
E
E
f]
eadang
Banjarmasin
Batitpapan
Pontianak
Patu
Makassar
￨￨￨￨￨■
ililllll
fl tvtanado
E t<upang
E Mataram
fl Rmuon
! Jayapura
f] Manokwari
￨￨
20. Checklist of documenta
evidence*
'[Yes n N/A
flYes D Nn
copies of birth certificate or equivalent
proof citizenship i.e. KTP or your passport personal information pages
E]Yes
□ N/A
IEコ Yes
□ N/A
l[コ Yes
□ N/A
current Curriculum Vitae (CV)
official (ce rtifi ed* ) post-secondary and tertiary ce rtifi cates/d eg rees
lo“idal(certitted・ )pOSt― Secondary and teniary transc薔
pts ofresuLs
.r"".i (*.|gj;iDlEifs
ol. TOEFL English language test results (a testresult obtained
in 2014 or 2015 will be considered current), TOEFL Rlediction test is NOT accepted.
I'rcrlDurrPt
and transcript
Masters applicants must also attach certified Dlll degree certificate drru
using DrV or s1 extension
certificate/flanscriRt
Doctorate applicants must also attach certified S'l degree certificate and
r'
if
Doctorate and those Masters applicants whose study will include at least fifty
research must fill the research proposal details on this application
form
percent
recent photograph (3 x a)
1 0mcial(certined★ )Eng‖ sh translations of post― secOndary and tertiary
l certilcates/degrees
official (certified' ) English translations of post-secondary and tertiary transcripts of
results
references from S1 supervisor for Masters candidates (if available)
applicants)
of relevant Oublfcations, unPubl]shed theses (for
lesearch
list
' statement from university that English is a language of instruction (if applicable)
1 0ffiCial(Certifled彙 )English translations of birth certincate
t[ves
n
Nn
transcript ' flYes E N/A
academic reference from 52 supervisor for Doctorate candidates
relevant correspondence with an Australian university (if available).
[]yes E N/A
‐
Eコ Yes
□ N/A
1_1yes
L
□ N/A
Yes
□ N/A
Yes
IEコ
ヽ
□ N/A
:□ Yes
□ N/A
￨□ Yes
□ N/A
□Yes
□ N/A
□Yes
□ N/A
E]Yes
□ N′ A
flves
E un
Eヨ
r9す
ィ
ヽPPl19,rtl,o11い:1114'19■ ,lgr99響 1聖 t919ф
=1110n and Sig,11■
Authorisation
lDFAT miJst ccinply with the Prirac/ス
:
21,
ヽ
crィ
:
988 in relation to the personalinformation you have provided in this form
l By submitting thls form l authorise DFA￢ 「,orits appointed rnanaging contractor,to access and/or obtain information,
including copies of any ofiny relevant academic records′
i forthe fo‖
l
o
repotts from the education institution(s)thati have attended
owing purposes:
for use in the selection process for an Australia Award
・ to monlor my academic performance at my hostinstluton while studying under an Australia Award
● to brief relevant Austra‖ an omcials,Ministers and members of Parliament
l
l
ll consentfor DFAT,orits appointed managlng contractor,to share this app‖ cation form and supporting documents
l with the government of my country of citizenshiplifthe government:s invoived in the Austra!ia Awards scholarship
.selection process.
:Shou!d!receive an Austra‖ a Award l consent
la)tO the Australian Government using and disclosing extracts of my applicalon(relaung tO my academic background
alin hardcopy
l and achievements,!eadership skills and my proposed study program in Australia)in prOmolonal mate百
l and on the lnternet.l note that promotional material rnay include:butis not‖ mited toi media releases and information
l circulated to DFAT's offshore Posts and Austra‖ an educatlon institutions,concerning the Austrana Awards.
y members and dependants:including senslive
:infOrmation as defined ln the Privacy Act 1 988:being co‖ ected,handled:used and disclosed by and exchanged
l betWeen DFAT:other 9overnment agencies including Australian immigration authorities,Austra‖ an education
l institutionsi partner organisations(including managing contractors and sub‐ contractors),mediCalinsurers,medical
l praculoners,case managers,the home government(where app:icab!e)and Other parties,in the circumstances
l outlined,and forthe purposes indicatedlin the Austra‖ a Awards Scholarships Po‖ cy Handbook as updated from time
:b)tO my personalinformalon and that of my fam‖
l to tirne.
:l authorise DFAT to disciose the personalinforrnation co‖
ected in this form to other Australian(3overnment
‐departments and Australian education institutions forthe purpose of promoting and managing the Australia Awards
l Understanding
ll understand and conflrm that:
￨
・ l have read and complied with the Scholarships Policy Handbook and thatthe contents of my applicalon are
true and correct
● DFAT has the rightto vary or「 9verSe any decision regarding a scholarship made on the basis ofincorrect or
l
l
l
inCOmplete informalon
l
・
‐
Decis!ons ofthe selection panel are inal and conndential and no correspondence about outcomes ofthe
selection process wi‖ be entered into.
:Agreement
llf SuCCessfulin gaining an Australia Award:l agree thatl vvi‖
￨
l
・
l
・
l
‐
‐
‐
.
o
・
:
under9o a po‖ ce or character check before my Austra‖
irnmediately provide l)FAT with deta‖
Award
a Award is conlrmed
s of any incidentthat rnay renect badly on the prestige of an Australia
actin a manner bentting a reciplent of an Australia Award
use the funds forthe purposes granted
acknowledge the assistance given by the Australian(3overnmentin any written reports,publications or
publicity associated with the Award.
Declaration and acknowiedgement
‐l declare:in subnlitting this app‖ cation formi thatthe information contained in it and provided in connection with itis
‐
true and correct.
Full Name
Signature
:Date
ノ
ノ
22,N9甲 in411■ gハ g9■ 9y
p991・
=oti9,I roqlir,0 12r F‖
l111,99191 appliC,11,9nlyt
￨(NB:to be completed by the staff member within your organisation authorised to release stafffor overseas study― for
rOm the lnternalonal Relalons Bureau(BKLN)′ Centre for Educa‖ on and ttraining/the Planning
I Bureau/Rector from the university as appropriate.Applicants from outside」 akarta must have the approva!and
i exampiC Staffヤ
l nomination oftheir relevant Kakanwi!or Kadinas and approvalfrom Bupati or Governor(or representative)Where
l necessary.)
I PleaSe nOte that your signature on this form signmes yOur agreementto the fol!owing:
: ・ to release the app‖ cantfrom work duties while heノ she attends Engiish for academic training.This training is
‐
fu‖ ‐
time and compu!sory
l
e
l
sh for academic training to study in Australia,and process
to release the app!icantfrom work duties after Eng‖
their omcia!passport and exit permit
l
・
to coverthe cost oftravelto and from Engiish for Acadenlic Purposes training(Baliノ 」akarta)
￨
・
tO Select a fie!d of study and level of study appropriate to the agency:s needs.
IP!ease also note thatif the application is for Doctorate leve!study:the signature by the authorised staff member
l conlrms that the applicantis a lecturerrresearcher/key planner or policy rnaker and that Doctorate leve!studies are
l eSSentia!for his/her future research andノ or teaching responsibilities.
Name of Ministry/Employer
Name of Applicant
Applicant's Position title
Applicant's Level of position
in organisation structure
(eg. Echelon and Golongan)
:
二」
Date commenced l
'
How long have you known the applicant and in what
capacity?
￨
ptease mare iny iooitionir aommanas aooui tne
applicant's potential or personal qualities which you feel
would be helpful to the Australia Awards Scholarships
Selection Team.
上
M
i
nistrv/Aqencv Representative siqnature*
On behalf of the ministry, I the undersigned, agree to be bound to the above commitments and strategies
Fu‖
Name
Position
I Emall
'Mobi!e
l Date
r
Signature & stamp
‐
23. IVlinistry of State Secretariat of the Republic of Indonesia use only
'
Endorsement by the Government of lndonesia
( To be completed by Head, Bureau of Technical Cooperation, Ministry of State Secretariat
lndonesia )
On behalf
of the Republic of
of the Government of lndonesia, 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.
_l
:n!9!1.
!._3!![algSllysl*
A*1$ r.hg:rge:---__-
Name of certifying officer
TiJe
Organisation
omcia:stamp
l signature
i
Date
ノ
′