Australian Development Scholarships

2012 Intake Application Form Instructions

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

> Before completing this form, you must read the Australia Development Scholarships Handbook (The Handbook)
and your Countrys profile, available on the AusAID Website (see below) or from the AusAID/Managing Contractors office in Indonesia. Brief information about the program is also included in this application form. Also see www.adsindonesia.or.id

> You must complete all fields marked with an * and all relevant sections. > This application must be completed in English.
> For Yes or No questions, indicate your response with an X in the appropriate box.

> Three (3) copies of this form and of all attached documents must be received by 26 August 2011 at the Australia Awards Office at Gedung Wirausaha, 7th Floor. Jl. H.R. Rasuna Said Kav.C-5 Kuningan, Jakarta 12940. > DO NOT send this application to universities or other institutions in Australia. > Australian Development Scholarships will be offered only to those whose course of study will contribute
to the long-term development needs of Indonesia. A list of the development priorities is available under Choosing a Course of Study on page 3 of this application form.

> AusAIDs website includes a list of Australian Universities that may receive Development Scholarship awardees.
Course of study information is available directly from the Universities websites or the Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS) website (see below).

> You may provide two preferences for courses of study. You should consider two Australian universities rather
than two courses at the same university, just in case you do not meet the admissibility requirements of the first Australian university.

> If your application is successful, you will be required to sign a Contract with the Commonwealth of Australia and
be bound by conditions of the scholarship. A full list of the conditions is contained in this application form (page 27 28) and in the Handbook. Please note that AusAID reserves the right to change these conditions at any time.

> Submitting this application does not guarantee that you will receive a Scholarship. > If you do not receive an invitation to an interview from the Australia Awards Office by mid-December, you should
assume that your application has been unsuccessful.

> Before applying, all Public sector applicants are required to have section 23 of the form completed by the
relevant training or foreign cooperation bureau or their university rector (whichever is applicable).

> Applicants in the Open category are not required to fill in section 23. Their applications are to be submitted
directly to the Australia Awards Office at the address above.

> Applicants must not fill in section 25. This section is for use by the Ministry of State Secretariat of the Republic of
Indonesia (SetNeg) and refers only to selected candidates.

> In cases where information supplied by candidates is found to be inaccurate or incorrect, an award offer may be
revoked without notice.

The closing date is 26 August 2011 Applications should be submitted as early as possible

General Information Notes

Australian Development Scholarships (ADS) provide opportunities for Indonesians to study in Australia at POSTGRADUATE level. Up to four hundred scholarships are expected to be awarded in 2012 for commencement in 2012/2013. Candidates must undertake study in one of the four areas of development priority (see page 3). ADS are offered in two main categories: Public Sector Category and Open Category. Public sector applicants are employees from Government organizations, state universities and state owned enterprises. Their applications must be approved by training or foreign cooperation bureaus (BKLN) of their local or central agencies before being submitted to the ADS Program Office. Public sector candidates from government agencies outside Jakarta may apply directly to the ADS Program Office with the approval of their relevant Kakanwil or Kadinas. Calon Pegawai Negeri Sipil are not eligible to apply. Open Category applicants are from private organisations and universities and this category is also open to recent university graduates. No prior Government approval is required for people applying in the Open Category, and applications are to be submitted directly to the Australia Awards Office. They require, where relevant, the endorsement of the agency, institution or private university in which the applicant is working or studying. Applications are submitted directly to the Australia Awards Office. Public servants (Pegawai Negeri) cannot apply in the Open category. A third category (Targeted) exists for candidates who are identified by their organisations in consultation with the ADS Program. Candidates within this category must be identified by their home organization and must not apply to the ADS Program independently of their employer. `Targeted Category' candidates are employed by organisations which are identified by the Government of Indonesia and Government of Australia (through AusAID) as being strategically aligned with the Development priorities of the Government of Indonesia. 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 must achieve satisfactory results in this training to be able to continue their scholarships. Applications from people with disabilities or from people in organisations working with the disabled are encouraged to apply. Women and candidates in provinces within the geographic focus of AusAID's Country Strategy (see page 4) are also encouraged to apply.

Eligibility
IN GENERAL CANDIDATES MUST:
> be an Indonesian citizen and not have permanent residence in Australia or New Zealand > not be married or engaged to a person who is eligible to hold Australian or New Zealand citizenship or permanent resident status, at any stage of the application, selection, mobilisation processes or while on-scholarship in Australia > satisfy Australian Government requirements for international student entry to Australia (health, character etc)

> not hold or have held a Government of Australia Scholarship to study outside Indonesia in the 24 months
preceding the application 24 months to be calculated from the date of arrival back in Indonesia to the Scholarship application closing date > be applying to commence a new course of study and not be seeking support through ADS for a course already commenced in Australia. > be able to take up the scholarship in the year for which it is offered

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

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

SPECIFICALLY, CANDIDATES MUST:

> be applying for courses that fall within the areas of development priority (see Choosing a Course of Study
below) > at the time of application, be no more than 42 years of age

> have a Grade Point Average (GPA) of at least 2.9 on a scale of maximum 4.0 (or 2.75 for applicants from geographic focus of AusAID Country Strategy only, see page ii) and an English language proficiency of at least 5.0 in IELTS (or 500 in paper-based TOEFL or 39 in Internet based TOEFL). The IELTS or TOEFL result must be current (a test result obtained in 2010 or 2011 will be considered current). No other English language test (including TOEFL prediction test) results will be accepted. Contact details of test centre must be provided for verification of TOEFL test results. > > > already hold an undergraduate degree, if applying for a Masters already have a Masters, if applying for a Doctorate apply for a degree at a level higher than their current highest qualification

> if applying for a Doctorate, applicants will be restricted to staff of universities, higher education institutions, research institutes, key policy makers and targeted candidates in other agencies associated with AusAID activities > it is highly desirable for Doctorate applicants to have a letter of support from an Australian university for their proposed field of study > answer all relevant questions on the application form

> be willing and available to undertake full-time (Monday - Friday 0800-1600) English for Academic Purposes
(EAP) training in Indonesia prior to studying in Australia, if offered a scholarship.

Choosing a Course of Study

Candidates are encouraged to apply to study courses which fall within AusAID's priority development areas (PDA). The PDA relate directly to the strategic objectives contained in the Australia and Indonesia Country Strategy. An indicative list of the areas for study follows.
Australia Indonesia Partnership Priority Development Areas (PDA) Description of PDA

Sustainable Growth and Economic Management Improving economic policy and management, reducing constraints to growth in infrastructure and productivity, and improving natural resource management, environmental governance and response to climate change. Natural Resource Management Agriculture Aquaculture/fisheries Forestry Climate Change Economics Infrastructure Planning Water and Sanitation Rural Growth Small and medium enterprise development

Democracy Justice and Good Governance Strengthening the capacity, accountability and responsiveness of legal, democratic and oversight institutions, and improving local government and public financial management.

Investing in People

Safety and Peace

Better quality, access and governance in education, and better health access and systems

Improving responses to humanitarian needs, emergencies and vulnerability to disasters, and improving capacity to ensure transport security and to counter threats from transnational crime. Conflict Resolution Disaster Prevention and Management Transport Safety Transnational Crime Prevention Development Studies International Studies

Australia Indonesia Partnership Priority Fields of Study

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 Development Childhood Special Education

NB: If your study area is not listed here, you may still apply for a field of study related to the work of AusAID in Indonesia. For more information see the Australia Indonesia Partnership Country Strategy at: http://www.indo.ausaid.gov.au/docs/aipstrategyinfo.html Candidates considering study for particular professions should note that ADS does not include the practical training period required for professional registration, e.g. medical internships, legal articles etc. Successful awardees are expected to complete such training in their own country.

Selection Process
All applicants are considered by an independent Joint Selection Committee comprised of Australian and Indonesian academics. Only those shortlisted will be interviewed. The interview will assess candidates' academic ability, clarity of study goals, cultural adaptability. A critical consideration will be how well the ADS applicant is able to explain 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 awardees is subject to scrutiny and endorsement by AusAID and Government of Indonesia - State Secretariat.

SELECTION QUOTAS:
In the 2011/2012 ADS cycle, up to four hundred (400) ADS scholarships are available for commencement in 2012/2013. The scholarships are allocated as follows:

> 2/3 of all awards will be offered in the `Public Sector' category > 1/3 of all awards will be offered in the `Open' category > up to 50 percent of awards will be offered in the Targeted Sector Category > up to 30 percent of all scholarships will be awarded in line with geographic focus of the Country Program
Strategy. (The geographic focus will include East Nusa Tenggara, West Nusa Tenggara, Papua, West Papua, and Aceh)

> 90 percent of awards at Masters level (360) and 10 percent at Doctorate (PhD) level (40). (NB doctoral level
study is only open to staff of universities, higher education institutions, research institute, key policy makers and targeted candidates in other organizations associated with AusAID activities. Up to eight (8) PhD awards will be made available to eligible candidates within the Targeted Category > an equal number of awards will be offered to men and women.

NOTIFICATION OF THE SELECTION RESULT

All applicants will be advised whether or not they have been selected for an interview. All interviewed applicants will be notified whether or not they have been awarded an ADS. The result is final and no correspondence will be entered into. Where appropriate, notification will include details of pre-departure training (English, academic skills, cultural preparation). This training is compulsory and full-time (see page 6 for step by step of ADS Application Process).

Requirements for Scholarship Recipients

Prior to travelling to Australia, scholarship recipients must:
> meet the minimum English language requirement of their chosen Australian university (usually IELTS of 6.5 with no band less than 6.0)

> at the completion of EAP training, candidates must achieve a minimum score of IELTS 6.0 for ADS office to
commence the application process for placement in a university program in Australia > > > receive a letter of acceptance from an Australian university meet Australian immigration requirements for a student visa receive Government of Indonesia endorsement

> be medically fit to commence studies in Australia.

In Australia, scholarship recipients must:

> > abide by the conditions of the scholarship and the rules of Australian tertiary institutions abide by the rules and regulations governing a student visa

> act in a way that will not bring disrepute to AusAID, or to any Australian university or to Indonesia > return to Indonesia for a period of two years at the completion of their study/research program in Australia. If
during the two years exclusion period the scholarship recipients return to Australia, a debt to the Commonwealth may be activated OR any time spent in Australia may be added to the two year exclusion period. Calculation of the two years exclusion period starts when the scholarships recipients arrive Indonesia, not the visa expire date.

What do Australian Development Scholarships cover?

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

> Tuition Fees - payment of full academic fees and any other fees compulsory for international students.
> Introductory Academic Program (IAP) the provision of a 4-6 week Introductory Academic Program prior to the commencement of studies. > Editorial/tutorial assistance - provided where it is deemed essential to assist awardees to pass course subjects.

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

> Overseas fieldwork - holders of a scholarship where research comprises at least 50 percent of the program may
receive a return economy class airfare to Indonesia to undertake essential fieldwork.

> Contribution to living expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses
(CLE). > Overseas Student Health cover (OSHC) - awardee only (awardees are required to maintain OSHC for any accompanying family in order to satisfy visa requirements).

> Provision of an AusAID Student Visa and Student Dependant visa.

Family Entry
Awardees can bring their immediate families to Australia at their own cost, if their families meet AusAID and immigration requirements. Families are normally permitted to join eight (8) weeks after the awardee's arrival.

Useful websites
Australia Awards: http://australiaawards.gov.au/ Australia Awards Development Scholarships: http://www.ausaid.gov.au/scholar Australian Development Scholarship (ADS) Indonesia: http://www.adsindonesia.or.id Visas Department of Immigration and Citizenship: http://www.immi.gov.au Studying in Australia: http://www.studyinaustralia.gov.au Australian Educational Institutions and courses - the Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS): http://cricos.deewr.gov.au IELTS: http://www.ielts.org.au
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TOEFL: http://www.ets.org/toefl

The ADS Application Process

Step 1 Applicant sends complete ADS application form to Australia Awards Office by 26 August 2011.

Step 2 Applicant is notified of the result of selection for interview by December 2011.

Step 3 Applicant selected for interview receives information of interview/ IELTS test date/location.

Step 4 Applicant attends interview and IELTS test in January 2012.

Step 5 Applicant is advised of the result of their ADS application by February 2012.

Australian Development Scholarships

2012 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* Given name* Family names* Date of birth* Place of birth* (State/province)

Mr Dr specify) WAHYU SUDRAJAT 31/ 7/ 1980

Mrs

Ms

Miss Other(Please

Enter your family name and other names as shown in your Birth Certificate, Passport or other official identification document. If you have only one name, enter it in both fields. dd/mm/yyyy

Tasikmalaya/Jawa Barat

Gender* Female Ethnic group?

Male Sunda

Which country are you living in now?* Pangkajene dan Kepulauan (Pangkep), Indonesia Have you applied, or are you intending to apply, for permanent residency or citizenship in Australia or New Zealand?* National Identity Number (KTP No.) Passport no. (provide if you have a passport).*
7310043107800001

Yes

No

Issue date / /

Expiry date / /

2. Contact details Residential address (Please check that your contact details are correct. Address line 1* Address line 2 Address line 3 Town/City* State/Province* Country*
The scholarship application takes several months to be finalised. If you cannot be contacted, your application will not proceed.)

Rumah Dinas Hakim IV, Jalan Andi Mauraga Nomor 78 Pangkajene South Sulawesi Indonesia Postal code (if
any)

90611

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 Country Phone and email Home phone no.* Mobile no. Email 1 Email 2

Pengadilan Negeri Pangkajene, Jalan Sultan Hasanuddin Nomor 38 Pangkajene South Sulawesi Indonesia Postal code (if
any)

90611

(Provide at least one contact number.) 08114212135 Work phone no. Fax no. (if
any)

(0410) 21221 or 21224

[email protected]

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

Address line 1* Address line 2 Address line 3 Town/City* State/Province* Country*

Pengadilan Negeri Pangkajene, Jalan Sultan Hasanuddin Nomor 38 Pangkajene South Sulawesi Indonesia Postal code (if
any)

90611

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 Given name* Yulia Family Helmisari names* Date of birth* 3/ 7/ 1980 Passport no.
Provide if spouse has a
Provide family name and other names as shown in your spouses birth certificate, passport or other official identification document*

dd/mm/yyyy

Indonesia

Gende Male Female r* 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 and has 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 Citizenship website or by contacting the university where you want to Child 1 Will this child accompany you to Australia?* Yes No Family name Given names Date of birth Country of citizenship Passport no.
Provide if child has a passport.*

Azzam Dzikri 29/ 9/ 2008

Indonesia

dd/mm/yyyy

Gender

Male

Female

Issue date Expiry date

/ /

/ /

Child 2 Family name Given names Date of birth Country of citizenship Passport no.

Will this child accompany you to Australia?* Akram Zaidan 12/ 10/ 201 0
Indonesia

Yes

No

dd/mm/yyyy

Gende r
/ / / /

Male

Female

Provide if child has a passport.*

Issue date Expiry date

Children details continued Child 3 Will this child accompany you to Australia?* No Family name Given names Date of birth Country of citizenship Passport no.
Provide if child has a passport.*

Yes

/ /

dd/mm/yyyy

Gende r
/ / / /

Male

Female

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. Mr Mrs Ms Miss Dr Title* Please Other specify Relationship Family name* Maryati to you* Given name* Home phone* Mobile phone Email 1 Email 2 Address line 1* Address line 2 Address line 3 Town/City* State/Province* Country* Eti (0265) 338293 081323337772 Jalan Pembela Tanah Air, Belakang 91 B, Gunung Roay Tasikmalaya West Java Indonesia Postal code (if
any)

Gender* Work phone Fax (if any)

Male

Female

46115

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?* 1. Scholarship/fellowsh Start date End date Country Qualification (if applicable) University

Yes

No

Country

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Previous scholarships continued 2. Scholarship/fellowsh Start date Qualification (if applicable) University

End date

Country

7. Scholarship applications Have you previously applied for an AusAID scholarship but were unsuccessful?* If "Yes" how many times have you previously applied for ADS? Have you previously been interviewed by ADS?* If Yes, in which years? 8. Disability Awardees with disabilities are encourage to apply for an ADS. If you do have a disability, the provision of details on disability will enable appropriate measures to be put in place in the ADS Program. Do you have a disability or do you work in a disability-focused organisation? Yes No Yes Yes No No

If "Yes", please give details and attach any medical assessment if relevant.

9. Under Which Category are you applying for an ADS? * Open If Open, please indicate if your application is from: Private university Private individual Public If Public, please indicate if your application is from: Government Department State-owned Enterprise State University

11

10. Proposed study program* AusAID will consider offering you a scholarship only if your course of study will contribute to the long-term development needs of your country. Note that the proposed program of study should be appropriate to your academic qualification and work experience. Requested Level of Type of study* (Masters Masters Coursework coursework program can study* (You will not be
allowed to upgrade your course from the level at which you are first placed).

Doctorate (PhD)

contain a research project up to 30% of the Masters. Candidate decide the topic during course)

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 Australia Indonesi a Partners hip Priority Develop Descripti on of PDA Sustainable Growth and Economic Management
Improving economic policy and management, reducing constraints to growth in infrastructure and productivity, and improving natural resource Natural Resource Management Agriculture

Democracy Justice and Good Governance

Strengthening the capacity, accountability and responsiveness of legal, democratic and oversight institutions, and improving local government and public financial Law, legal and judicial systems Political Science and Government Public administration Public expenditure management Public Sector Reform Environmental Law Anti-corruption

Investing in People

Safety and Peace

Better quality, access and governance in education, and better health access and systems

Improving responses to humanitarian needs, emergencies and vulnerability to disasters, and improving capacity to ensure transport security and to counter threats from transnational crime. Conflict Resolution Disaster Prevention and Management Transport Safety Transnational Crime Prevention Development Studies International Studies

Australia Indonesi a Partners hip Priority Fields of Study (PFS)*

Aquaculture/fis heries Forestry Climate Change Economics Infrastructure Planning Water and Sanitation Rural Growth Small and medium

Decentralisatio n

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

Other, please specify:

12

Proposed study program* continued Have you obtained information from the ADS Information CD, or from the ADS 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.

ADS - Australian Universities List Following Australian universities are under contract to AusAID to provide courses for ADS awardees. Awardees 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 Australian university and course of study. You need to decide which Australian university you want to attend and choose an appropriate course. You should choose two courses of study. You are encouraged to choose two different Australian universities rather than two different courses at the same university. If your application for the first choice of study is unsuccessful, AusAID will forward your application to your second choice. The CRICOS code from your course can be found on the Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS) Website http://cricos.deewr.gov.au To find out about the content of specific courses, you should refer to the individual Australian university websites. This information can also be found on the ADS Information CD which can be obtained from the Australia Awards Office or ADS website http://www.adsindonesia.or.id. Preference 1*

13

Course title or particular focus area within your identified proposed Field of CRICOS code (if
applicable)*

Australian University
(if applicable)

Course duration (weeks)

(if applicable)

Minimum English language proficiency required for the course (IELTS) (if

14

Proposed preferences continued Preference 2* Course title or particular focus area within your identified proposed Field of Study.* CRICOS code (if
applicable)*

Australian University
(if applicable)

Course duration (weeks)

(if applicable)

Minimum English language proficiency required for the course (IELTS) (if

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

Yes

No

Yes

No

If "Yes" please give details. (Note that ADS 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).

15

Research proposal details Complete this section if the studies will be by Research or a combination of Research and Coursework. E.g. Doctorate or Masters by Research. Otherwise proceed to next question. Answers should be concise but sufficient to explain the nature of your research proposal to the selection panel. Please note word limits. Anything over this limit will not be considered. Research title (max 250 characters, approx 30- 50 words limit) What is the background to the research being proposed? (maximum 150 words / + 1,000 characters)

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) What hypothesis are you testing in your proposed research? (maximum 50 words / + 350 characters) What are the objectives of the proposed research? (maximum 200 words / + 1,300 characters)

16

Research proposal details What is the methodology/struct ure in your proposed research? (include comments on measurements, data sources, methods of analysis and timelines) (maximum 200 words / + 1,300 characters) Have you published any research to date? (include texts, journal articles providing full citation)

Which university do you consider appropriate for your proposed studies? Why? (maximum 50 words / + 350 characters) Have you considered a possible research supervisor? Why this selection? (maximum 50 words / + 350 characters) What is the relevance of the proposed research to Indonesia?

Does your proposed research include Yes No Not sure fieldwork?* If `Yes please provide a description of the fieldwork you will be undertaking. (Max 1000 characters, approx 200 words limit).

What is the duration of your proposed fieldwork? (if known) In which country will you undertake the proposed fieldwork? Proposed fieldwork supervisor (if known)

Weeks
17

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. Three certified copies of official transcripts and certificates MUST be included with this application. If you are selected for interview, you MUST provide certified English 1. Qualification name* Secondary (High School) Vocational, Technical Level of study* ( DIII or DIV ) Name of university* State/Province Country* Start date * End date*
/ / / /

Language of instruction* GPA (if applicable) Status 2. Qualification name* Level of study* Name of university* State/Province Obtained / Max Complete

Pending results

Incomplete

Secondary (High School) Vocational, Technical ( DIII or DIV ) Country* Start date* End date*
/ / / /

Language of instruction* GPA (if applicable) Status 3. Qualification name Level of study Name of university State/Province Language of instruction GPA (if applicable) Status Obtained / Max Complete

Pending results

Incomplete

Secondary (High School) Vocational, Technical ( DIII or DIV ) Country Start date
/

Obtained / Max End date / / 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 39 in internet-based TOEFL). The IELTS or TOEFL (Institutional or International) result must be current (a test result obtained in 2010 or 2011 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 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? Test name Date (e.g. IELTS or test TOEFL) taken Test Phone Centre/locatio If `No, when do you expect to complete the test? 13. Computer literacy*

Yes
//

No Overall score

Website Test name

//

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?* How regularly do you use a PC?*
Monthly

Yes
Occasionally

No
Daily Weekly

Do you have experience with the following software?* Word processing software (e.g. Word)? Database software (e.g. Access)? Presentation software (e.g. PowerPoint)? Internet browsers (e.g. Internet Explorer)? Yes No Yes No Yes No Yes No Spreadsheet software (e.g. Excel)? Operating systems (e.g. Windows 2000)? Email software (e.g. Outlook)? Statistical packages (e.g. SPSS or Minitab)? Yes No Yes No Yes No Yes No

14. Computer training details List any formal computer courses you have undertaken. Course name 1 Start date Course name 2 Start date / / / / End date / / End date / /

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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. Position title* Judge Organisation* Level of position in organisation structure (eg. Echelon and Golongan) Sector/organisation type Briefly describe the work of your organisation and the service it provides. Pengadilan Negeri Pangkajene (Court of Pangkajene)

III/b

Date commenced*

/ /

Government/Public Private

NGO /Civil Society

Briefly describe your current duties and responsibilities (max 500 characters, approx 80-100 words limit)

Do you intend to return to this organisation after your scholarship in Australia?* If Yes, what role and responsibilities do you expect to undertake after your academic studies? (max 500 characters, approx 80-100 words limit)

Yes No

What specific tasks do you anticipate being able to undertake after your academic studies? (specify at least 3) (max 500 characters, 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 work experience, community work and voluntary work. 1. Previous position Position title Organisation Start date Duties/responsibilitie s (max 500 characters, approx 80-100 words limit) / / End date / /

2. Previous position Position title Start date Organisation Duties/responsibiliti es (max 500 characters, approx 100 words limit) / / End date / /

17. Interview Centre * Please tick your preferred interview center. (Please note Your choice is not guaranteed.) Jakarta Yogyakarta Surabaya Denpasar Balikpapan/Banjarmasin Jayapura Medan Padang 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?*

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

3. How will the proposed training be of benefit to Indonesia?*

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Supporting statement continued 4. Do you currently have any connection or relationship to any staff employed at AusAID Posts or with AusAIDs managing contractors?*
If `Yes please expand.

Yes

No

5. Are you subject to any criminal or civil proceedings that are currently awaiting legal action?*

Yes

No

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

6. Is there anything else you would like to add? (E.g. Will you require special assistance or equipment to participate in the Scholarship selection processes

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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 2. Organisation Name Highest position held (if any) Start date 3. Organisation Name Highest position held (if any) Start date Start date IKATAH HAKIM INDONESIA (IKAHI) / / / / / / / / End date / / End date / / End date / /

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

AusAID scholarship recipient Friend, relative or colleague Australian Embassy or Australian Education Centre
(specify location)

Australia Awards website AusAID Website Australian institution or university

(specify)

AusAID or Managing Contractors Office Home institution or university Publication, Radio, TV (specify)

Workplace or nominating authority (specify)

asked to do so)

Other
(specify)

From where did you obtain your application form? (tick box and specify where ADS website Friend, relative or colleague Education Agent
(specify)

ADS Office DEEWR Office Home institution or university (specify) Other

(specify)

AusAID Office GoI State Secretariat Office AusAID project office

(specify)

Workplace or nominating authority (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.

THREE COPIES of the completed application form. At least one copy of the application form should have certified* copies attached of the relevant documents listed below. Where original documents are not in English, you must provide certified* copies of official English translations if you are selected for an interview.
* Certified: a statement that the document is a true copy, signed by a Commissioner of Oaths, Public Notary or other formally recognised authority. If you are unsure about who is the appropriate person to certify your documents, you should contact the ADS 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 proof citizenship i.e. KTP or your passport personal information pages current Curriculum Vitae official (certified* ) post-secondary and tertiary certificates/degrees official (certified* ) post-secondary and tertiary transcripts of results current (original) IELTS or TOEFL English language test results (a test result obtained in 2010 or 2011 will be considered current). TOEFL prediction test is NOT Yes Yes Yes Yes Yes N/A N/A N/A N/A N/A

Yes

N/A

accepted.
Masters applicants must also attach certified DIII degree certificate/transcript if using DIV or S1 extension certificate/transcript Doctorate applicants must also attach certified S1 degree certificate/transcript academic reference from S2 supervisor for Doctorate candidates 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 form Yes Yes Yes Yes N/A N/A N/A N/A

Additional Documents: (Optional) Applicants must provide the following documents if they are selected for an interview. recent photograph (3 x 4) official (certified* ) English translations of post-secondary and tertiary certificates/degrees official (certified* ) English translations of post-secondary and tertiary transcripts of results references from S1 supervisor for Masters candidates (if available) list of relevant publications, unpublished theses (for research applicants) statement from university that English is a language of instruction (if applicable) relevant correspondence with an Australian university (if available). Yes Yes Yes Yes Yes Yes Yes N/A N/A N/A N/A N/A N/A N/A
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official (certified*) English translations of birth certificate

Yes

N/A

IMPORTANT: Attach only certified copies of documents. DO NOT attach 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 your scholarship 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 of these 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 main conditions are set out below for your information. In accepting an Australian Development Scholarship, you will be asked to: take up the ADS in the academic year for which it is offered; complete a full study program during the course of their scholarship; not hold another Australian Government scholarship at the same time as the ADS; participate in the Pre-Departure Briefing arranged by the Post, and the universitys compulsory Introductory Academic Program (IAP) on arrival in Australia; reside in Australia for the duration of the ADS (apart from holidays, reunion visits or fieldwork visits to their home country); complete their ADS award within the period stipulated in their Student Contract; only undertake the approved program for which the ADS is offered and abide by the rules of the university; maintain an appropriate study load and achieve satisfactory academic progress in the program for which the ADS 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 before any 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. The change in a students marital status may affect eligibility to maintain the ADS Scholarship, and the Debt to the Commonwealth may apply if the student does not return to their home country 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
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Residence or for a visa to remain in or return to Australia within the two year 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 ADS may be terminated at any time for failure to make satisfactory academic progress, failure to comply with the laws of Australia, misconduct, breaches of the contract between the Student and the Commonwealth of Australia including breaches of the conditions of the ADS or of the AusAID Student Visa or if they apply to change their visa status.

Conditions of Scholarships continued Subject to your fulfilling these conditions AusAID will provide the following, (either directly or through the Australian university):

Pre-Course English provision of English for Academic Purposes training prior to commencement of studies in Australia (including an in-Indonesia stipend) Tuition Fees - payment of full academic fees and any other fees compulsory for international students. Introductory Academic Program (IAP) the provision of a 4-6 week Introductory Academic Program prior to the commencement of studies. Editorial/tutorial assistance - provided where it is deemed essential to assist
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awardees to pass course subjects.

Travel - payment of an economy airfare from the principal international airports in Indonesia (Jakarta or Denpasar) to the major airport nearest the Australian university and return travel to Indonesia. A separate reunion airfare will be available to the student after the successful completion of the first year of study; subsequent reunion airfare entitlements will be available on an annual basis for the duration of the ADS, except for the final year of the ADS. Overseas fieldwork - holders of a scholarship where research comprises at least 50 percent of the program may receive a return economy class airfare to Indonesia to undertake essential fieldwork. Contribution to living expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses (CLE). Overseas Student Health cover (OSHC) - awardee only (awardees are required to maintain OSHC for any accompanying family in order to satisfy visa requirements). Provision of an AusAID Student Visa and Students Dependant visa.

Your university will provide for: instruction and facilities necessary to complete the specified course appropriate academic and welfare support for the duration of your studies airport reception and temporary accommodation arrangements on arrival 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 - for example 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 their relevant Kakanwil or Kadinas.) Please note that your signature on this form signifies your agreement to the following: to release the applicant from work duties while he/she attends English 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 process their official passport and exit permit to cover the cost of travel to and from English for Academic Purposes training (Bali/Jakarta) to cover the cost of travel to the point of departure (Bali/Jakarta) prior to travel to Australia to cover the cost of medical examinations for the applicant. A medical examination is an Australian Immigration requirement to receive a student visa to select a field of study and level of study appropriate to the agency's needs.

Please also note that if the application is for Doctorate level study, the signature by the authorised staff member confirms that the applicant is a lecturer/researcher/key planner or policy maker and that Doctorate level studies are essential for his/her future research and /or teaching responsibilities. Name of Ministry/Employer Name of Applicant Applicants Position title Wahyu Sudrajat Judge of Pangkajene Court
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Applicants Level of position in organisation structure (eg. Echelon and Golongan)

Date commenced

/ /

How long have you known the applicant and in what capacity?

Please make any additional comments about the applicant's potential or personal qualities which you feel would be helpful to the ADS 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 Signature & stamp Position 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 for the 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 Australian Development Scholarships to brief relevant Australian officials, Ministers and members of Parliament.

Should I receive an Australia Award, I consent to the Australian Government using and disclosing extracts of my application (relating to my academic background and achievements, leadership skills and my proposed study program in Australia) in promotional material in hardcopy and on the Internet. I note that promotional material may include, but is not limited to, media releases and information circulated to AusAIDs offshore Posts and Australian universities, concerning the Australian Development Scholarships. I authorise AusAID to disclose the personal information collected in this form to other Australian Government departments for the purpose of promoting and managing the Australian Development 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 Development 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 Development Scholarships, I agree that I will: undergo a police or character check before my Australia Development Scholarships is confirmed immediately provide AusAID with details of any incident that may reflect badly on the prestige of an Australia Development Scholarships act in a manner befitting a recipient of an Australia Development Scholarships use the funds for the purposes granted acknowledge the assistance given by the Australian Government in any 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 true and correct. I acknowledge that giving false or misleading information is a serious offence under the Criminal Code Act 1995 of the Commonwealth of Australia. Full Name Signature Date

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/ /

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

Endorsement by the Government of Indonesia

( To be completed by Head, Bureau of Technical Cooperation, Ministry of State Secretariat of the Republic of Indonesia ) On behalf of the Government of Indonesia, I certify that I have examined the 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 Australian Development Scholarship. Name of certifying officer Title Organisation Official Stamp Signature Date

/ /

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