Australian Development

Scholarships
2013 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 17 August 2012 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 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 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
25 - 26) and in the Handbook. Please note that AusAID reserves the right to change these conditions at any time.

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

> 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.

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 The closing date is 17 August 2012
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 and seventy five scholarships are expected to be awarded in 2013 for commencement in
2013/2014 including twenty five Australian Leadership Award Scholarships (ALAS). 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 and approval from Bupati or Governor (or representative) where necessary. 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 have obtained an academic qualification outside their home country in the 24 months preceding the
application closing date, calculated from the date of arrival back in the home country

> not be applying for another long-term AusAID scholarship unless they have returned to their home
country and resided there for twice the length of the total time that they were in Australia (for example, a
previous AusAID Scholar who has been on AusAID scholarship/s in Australia for five years will not be
eligible to apply for another AusAID scholarship until they have been home for ten years)
> 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

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

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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 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 (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 61 in Internet based TOEFL). The IELTS or TOEFL result must be
current (a test result obtained in 2011 or 2012 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.

> have a Grade Point Average (GPA) of at least 2.75 for awardees with a disability as declared on the ADS
application form.
> 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 Sustainable Growth and
Priority Economic Management
Development
Areas (PDA)
Description of Improving economic policy
PDA and management, reducing
constraints to growth in
infrastructure and
productivity, and improving
natural resource
management, environmental
governance and response to
climate change.
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 Improving responses to
and governance in humanitarian needs,
education, and better emergencies and
health access and vulnerability to
systems disasters, and
improving capacity to
ensure transport
security and to counter
threats from
transnational crime.

Australia Natural Resource Law, legal and Communicable Conflict Resolution

Indonesia Management judicial systems Disease Prevention Disaster
Partnership Agriculture Political Science and Health Prevention and
Priority Fields Aquaculture/fisheries Government Management Management
of Study Forestry Public administration Health Services Transport Safety
Climate Change Public expenditure Maternal and Child Transnational
Economics management Health Crime Prevention
Infrastructure Planning Public Sector Women and Development
Water and Sanitation Reform Gender Studies Studies
Rural Growth Environmental Law Disability Services International
Small and medium Anti-corruption Public Health Studies
enterprise development Decentralisation Education and
Monitoring & Training
Evaluation Education
Management
Human Resource
Development
Childhood Special
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 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 2012/2013 ADS cycle, up to four hundred and seventy five (475) ADS scholarships are available for
commencement in 2013/2014 including twenty five (25) Australian Leadership Award Scholarships (ALAS). 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)

> 85 percent of awards at Masters level and up to 15 percent at Doctorate (PhD) level. (NB doctoral level study
is only open to staff of universities, higher education institutions, research institute, key policy makers and
targeted candidates in other organizations associated with AusAID activities.
> an equal number of awards will be offered to men and women.

NOTIFICATION OF THE SELECTION RESULT

All applicants will be advised whether or not they have been selected for an interview. All interviewed applicants will
be notified whether or not they have been awarded an 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 7 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.

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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)

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

> Medical examination and x-ray costs in order to comply with Student Visa requirements
> AusAID Student Visa and Student Dependant Visa
> Outward Airfare (economy- one way) from the airport closest to the awardees home location to the international
airport closest to the Australian university selected for study by the awardee

> Overseas Student Health Cover (OSHC) - awardee only (awardees are required to maintain OSHC for any
accompanying family in order to satisfy visa requirements).

> Establishment Allowance payable into the awardees bank account after arrival in Australia
> Contribution to Living Expenses (in Australia Stipend) - payment of a fortnightly contribution to living expenses
(CLE).

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

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

> Supplementary Academic Support - provided where it is deemed essential to assist awardees to pass course
subjects.

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

> Reunion Airfare - is available to a single awardee 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.

> Homeward Airfare (economy- one way) from the international airport closest to the Australian university selected
for study by the awardee to the airport closest to the awardees home location..

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.

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 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.australiaawardsindo.or.id

Visas Department of Immigration and Citizenship: http://www.immi.gov.au

Studying in Australia: http://www.studyinaustralia.gov.au

Australian Educational Institutions and courses - the Commonwealth Register of Institutions and Courses for

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

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

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

The ADS Application Process

Step 1
Applicant sends complete
ADS application form to
Australia Awards Office by
17 August 2012.

Step 2
Applicant is notified of
the result of selection for
interview by December 2012.

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

Step 4
Applicant attends
interview and IELTS test
in January 2013.

Step 5
Applicant is advised of
the result of their ADS
application by February 2013.

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Australian Development Scholarships
2013 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 Attach a recent
document issued by your country of citizenship. passport size photo.
3 x 4 cm.
* Denotes mandatory field

Title* Mr Mrs Ms Miss Dr

Other(Please specify)
Given name* Bayu Anggileo Enter your family name and other names as
shown in your Birth Certificate, Passport or
other official identification document. If you
Family names* Pramesona have only one name, enter it in both fields.

Date of birth* 2/ 8/ 1986 dd/mm/yyyy Gender* Male

Female
Place of birth* (State/province) Kotabumi, Lampung

Which country are you living in now?* Indonesia

Have you applied, or are you intending to apply, for permanent residency or
Yes No
citizenship in Australia or New Zealand?*

National Identity Number

1803020208860002
(KTP No.)

Passport no. Issue date 20/ 7/ 2012

(provide if you have a A3268977
passport).* Expiry date 20/ 7/ 2017

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2. Contact details
Residential address (Please check that your contact details are correct. The scholarship application takes several months to be finalised. If you
cannot be contacted, your application will not proceed.)

Address line 1* Jl. Penatih Tuho no. 01 RT 002 RW 002 Kotabumi

Address line 2

Address line 3

Town/City* Kotabumi, North Lampung

State/Province* Lampung Postal code (if any) 34516

Country* INDONESIA

Mailing address(Provide details only if this is different to your current residential address.)

Address line 1

Address line 2

Address line 3

Town/City

State/Province Postal code (if any)

Country

Phone and email (Provide at least one contact number.)

Home phone no.* Work phone no. +62724 - 22095

Mobile no. +6285269712858 Fax no. (if any) +62724 - 22095

Email 1 ners.bayu@gmail.com

Email 2

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* Mayjend HM. Ryacudu General Hospital, Kotabumi. Jl.Jendral Sudirman No. 2 Kotabumi
Address line 2

Address line 3

Town/City* Kotabumi, North Lampung

State/Province* Lampung Postal code (if any) 34511

Country* INDONESIA

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3. Spouse details*
If you have dependants (spouse and/or children under 18 years of age), provide their details even if they will not
accompany you to Australia. Note that the scholarship does not provide financial support for accompanying dependants.
You can get information on your responsibilities for your spouse and any dependant children, should they live with you in
Australia during your scholarship, from the Department of Immigration and Citizenship (DIAC) or by contacting the
university where you want to study.
Given name* Provide family name and other names as shown in your spouses
birth certificate, passport or other official identification document*
Family names*

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

Passport no. Issue date / /
Provide if spouse
has a passport.* 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 study.

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

Family name
Given names
Date of birth / / dd/mm/yyyy Gender Male Female
Country of citizenship

Passport no. Issue date / /

Provide if child has a
Expiry date / /
passport.*

Child 2 Will this child accompany you to Australia?* Yes No

Family name
Given names
Date of birth / / dd/mm/yyyy Gender Male Female
Country of citizenship

Passport no. Issue date / /

Provide if child has a
Expiry date / /
passport.*

10
Children details continued

Child 3 Will this child accompany you to Australia?* Yes No

Family name
Given names
Date of birth / / dd/mm/yyyy Gender Male Female
Country of citizenship

Passport no. Issue date / /

Provide if child has a
Expiry date / /
passport.*

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*
Other Please specify

Relationship to
Family name* Rostana mother
you*

Given name* Yunarita Gender* Male Female

Home phone* Work phone
Mobile phone +6282177438318 Fax (if any)
Email 1
Email 2
Address line 1* Jl. Penatih Tuho No. 01 RT 002 RW 002 Kotabumi

Address line 2

Address line 3

Town/City* Kotabumi, North Lampung

State/Province* Lampung Postal code (if any) 34516

Country* INDONESIA Please check that the contact details are correct

6. Previous scholarships (attach a separate list if there is not enough space)

Only include details of post-secondary school scholarships or fellowships.

Have you previously been awarded a scholarship or a fellowship?* Yes No

1. Scholarship/fellowship
title
Start date End date Country

Qualification (if applicable)

University
Country

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Previous scholarships continued
2. Scholarship/fellowship
title
Start date End date

Qualification (if applicable)

University
Country

7. Scholarship applications

Have you previously applied for an AusAID scholarship but were

Yes No
unsuccessful?*
If "Yes" how many times have you previously applied for ADS? once
Have you previously been interviewed by ADS?* Yes No
If Yes, in which years?

8. Disability
AusAID strongly encourages applications from people with disability who are otherwise eligible for a Scholarship. Under the Disability
Discrimination Act, Australian education institutions have to provide 'reasonable adjustments' to students with disability to assist access to study.
To assess the likely support needs, appropriate assistance, and the capacity of relevant institutions to provide the assistance, 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 Institution's capacity. AusAID will advise the Institution of any special requirements associated with an
Awardee so that the Institution can pass these details to the Institutions Disability Liaison Officer prior to the Awardee arriving on-campus.
Where an Institution is not able to provide the assistance requested, other Institutions may be recommended.

Do you identify as having a disability or do you work in a disability-

focused organisation?*
neurological, learning disabilities, physical disfigurement, and the presence in the body of
Yes No
disease-causing organisms
(http://www.hreoc.gov.au/disability_rights/dda_guide/who/who.html)

If 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?

9. Under Which Category are you applying for an ADS? *

Open Public
If Open, please indicate if your application is from: If Public, please indicate if your application is from:
Private university Government Department
Private individual State-owned Enterprise
State University

10. Proposed study program*

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AusAID will consider offering you a scholarship only if your course of study will contribute to the long-term 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 study* Type of study* (Masters

Masters Coursework
(You will not be allowed to coursework program can contain a
upgrade your course from the research project up to 30% of the Research
level at which you are first Doctorate (PhD) Masters. Candidate decide the topic
placed). during course) Combination

Research background of Doctorate(PhD) candidates only:*

Do you hold a Masters degree with > 50% weighting for research? Yes No
Are you including a letter from your Masters supervisor recommending that you should pursue Doctorate
studies? (Recommended) Yes No

Proposed field of study*

You are required to:
Identify the priority Development Area (PDA) for your proposed studies. (Please tick one box only).
Identify the Priority Field of Study (PFS) from the list of preferred PFS provided (Please tick one box only).
If necessary, you may nominate another Field of Study in 'other' (Please tick other and provide detail).
Australia
Indonesia Sustainable Growth Democracy Justice Investing in People Safety and Peace
Partnership and Economic and Good
Priority Management Governance
Developmen
t Areas
(PDA)*
Description Improving economic Strengthening the Better quality, access and Improving responses to
of PDA policy and management, capacity, accountability governance in education, humanitarian needs,
reducing constraints to and responsiveness of and better health access emergencies and vulnerability
growth in infrastructure legal, democratic and and systems to disasters, and improving
and productivity, and oversight institutions, and capacity to ensure transport
improving natural improving local security and to counter
resource management, government and public threats from transnational
environmental financial management. crime.
governance and response
to climate change.
Australia Natural Resource Law, legal and judicial Communicable Conflict Resolution
Indonesia Management systems Disease Prevention Disaster Prevention and
Partnership Agriculture Political Science and Health Management Management
Priority Aquaculture/fisheries Government Health Services Transport Safety
Fields of Public administration
Forestry Maternal and Child Transnational Crime
Study
Climate Change Public expenditure Health Prevention
(PFS)* management
Economics Women and Gender Development Studies
Public Sector Reform Studies International Studies
Infrastructure
Environmental Law Disability Services
Planning
Anti-corruption Public Health
Water and Sanitation
Decentralisation Education and
Rural Growth
Monitoring & Training
Small and medium Evaluation Education
enterprise Management
development
Human Resource
Development
Childhood Special
Education
Other, please specify:

13
Proposed study program* continued
Have you obtained information from the ADS Information CD, or from the ADS
Yes No
website regarding study options in Australia?
Please describe the efforts you have undertaken so far to obtain information on your study options in Australia.
1. searching in the ADS website
2. discuss with the AusAID Scholarship recipient

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 Murdoch University University of Canberra
Australian Catholic University Queensland University of Technology University of Newcastle
Carnegie Mellon University RMIT University University of New England
Central Queensland University Southern Cross University University of New South Wales
Charles Darwin University Swinburne University of Technology University of South Australia
Charles Sturt University The Australian National University University of Southern Queensland
Curtin University of Technology The Flinders University of South Australia University of Tasmania
Deakin University The University of Adelaide University of Technology, Sydney
Edith Cowan University The University of Melbourne University of the Sunshine Coast
Griffith University The University of Queensland University of Western Sydney
James Cook University The University of Sydney University of Wollongong
La Trobe University The University of Western Australia Victoria University
Macquarie University UCL School of Energy and Resources Bond University
Monash University University of Ballarat 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*
Course title or particular focus Health Management
area within your identified
proposed Field of Study.*

CRICOS code (if applicable)* Australian University

(if applicable)

Minimum English
Course duration (weeks) language proficiency

(if applicable) required for the course
(IELTS) (if applicable)

14
Proposed preferences continued
Preference 2*

Course title or particular focus Nursing

area within your identified
proposed Field of Study.*

CRICOS code (if applicable)* Australian University

(if applicable)

Minimum English
Course duration (weeks) language proficiency

(if applicable) required for the course
(IELTS) (if applicable)

A formal offer of admission will not be required however it is expected serious

PhD candidates will have made preliminary enquiries to possible Australian
universities regarding their study.
Yes No
Have you discussed your proposed course with a member of staff from any
Australian university? This is highly recommended for PhD applicants. If Yes,
please attach any relevant correspondence with Australian universities.

Are there any special subjects or skills development that you would like to include
Yes No
in your choice?

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/structure 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 fieldwork?* Yes No Not sure

If `Yes please provide a description of the fieldwork you will be undertaking. (Max 1000 characters, approx 200 words
limit).

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

In which country will you undertake the proposed fieldwork?
Proposed fieldwork supervisor (if known)

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 translations when you attend the interview.

1. Qualification name* Bachelor of Nursing

Secondary (High School) Vocational, Technical
( DIII or DIV )
Level of study*
Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university* Universitas Muhammadiyah Yogyakarta
State/Province Yogyakarta Country* INDONESIA
Language of instruction* Bilingual (Indonesia-English) Start date * / 9/ 2004
GPA (if applicable) Obtained 3,50 / Max 4,00 End date* 29/ 12/ 2011

Status Complete Pending results Incomplete

2. Qualification name*
Secondary (High School) Vocational, Technical
( DIII or DIV )
Level of study*
Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university*
State/Province Country*
Language of instruction* Start date* / /

Obtained / Max
GPA (if applicable) End date* / /

Status Complete Pending results Incomplete

3. Qualification name
Secondary (High School) Vocational, Technical
( DIII or DIV )
Level of study
Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university
State/Province Country
Language of instruction Start date / /

GPA (if applicable) Obtained / Max End date / /

Status Complete Pending results Incomplete

18
12. English language proficiency*

Applicant must have an English language proficiency of at least 5.0 in IELTS (or 500 in paper-based TOEFL or 61 in
internet-based TOEFL). The IELTS or TOEFL (Institutional or International) result must be current (a test result obtained in
2011 or 2012 will be considered current). An original copy of your IELTS or TOEFL certificate must be attached to the
application form. NO other English language test (including TOEFL prediction) result will be accepted.

Is English your first language? Yes No

If `Yes go to next section. If `No answer the following questions:

Was English the language of your highest level of study? Yes No

If `Yes, provide a statement from the university verifying the language of instruction.

Have you taken an IELTS or TOEFL test? Yes No

Test name (e.g. Date test // Overall
TOEFL 550
IELTS or TOEFL) taken score
Muhammadiyah University
Test Centre/location Phone Website
of Yogyakarta
If `No, when do you expect to complete the
// Test name
test?

13. Computer literacy*

Please answer the following questions to the best of your ability. This will assist Australian universities to decide whether
to provide additional tuition.

Are you computer literate?* Yes No

How regularly do you use a PC?* Occasionally Daily Weekly Monthly

Do you have experience with the following software?*

Word processing software Spreadsheet software (e.g.
Yes No Yes No
(e.g. Word)? Excel)?
Database software (e.g. Operating systems (e.g.
Yes No Yes No
Access)? Windows 2000)?
Presentation software (e.g. Email software (e.g.
Yes No Yes No
PowerPoint)? Outlook)?
Internet browsers (e.g. Statistical packages (e.g.
Yes No Yes No
Internet Explorer)? SPSS or Minitab)?

14. Computer training details

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

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.

19
Position title* Staff of Nursing Services Departement
Organisation* Mayjend HM. Ryacudu Hospital, Kotabumi, North Lampung
Level of position in
organisation structure III/a Date commenced* 1/ 3/ 2009
(eg. Echelon and Golongan)
Sector/organisation type Government/Public NGO /Civil Society Private
Briefly describe the work of
your organisation and the
service it provides.

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?* Yes No
If Yes, what role and
responsibilities do you
expect to undertake after
your academic studies?
(max 500 characters,
approx 80-100 words limit)

What specific tasks do you

anticipate being able to
undertake after your
academic studies? (specify
at least 3) (max 500
characters, approx 80-100
words limit)

20
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 / / End date / /
Duties/responsibilities
(max 500 characters,
approx 80-100 words limit)

2. Previous position

Position title
Start date / / End date / /
Organisation
Duties/responsibilities
(max 500 characters,
approx 100 words limit)

17. Interview Centre *

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

Jakarta Medan Makassar

Yogyakarta Padang Manado
Surabaya Balikpapan/Banjarmasin Kupang
Denpasar Jayapura

21
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 have you contributed to solving a challenge and to implementing change or reform? (Be specific and
include: what aspect/s 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.)?*

22
Supporting statement continued
4. What specific development priority will you contribute to on your return home and how do you intend to do
so?*

5. Do you wish to be considered for a supplementary Leadership Award?

Yes No
Refer to the Handbook for further details on the supplementary Leadership Award.

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

at AusAID Posts or with AusAIDs managing contractors?* Yes No

If `Yes please expand.

7. Are you subject to any criminal or civil proceedings that are currently Yes No
awaiting legal action?*to live and undertake studies in Australia?)
If `Yes please expand. Please note information provided here will not necessarily disqualify you from submitting this scholarship application.

23
19. Professional memberships
Professional memberships may include community, cultural, political, scientific, professional and/or educational
associations and organisations.

1. Organisation Name
Highest position held (if any)
Start date / / End date / /
2. Organisation Name
Highest position held (if any)
Start date / / End date / /
3. Organisation Name

Highest position held (if any)

Start date / /
Start 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 or Managing
AusAID scholarship recipient Australia Awards website
Contractors Office
Friend, relative or colleague AusAID Website Home institution or university
Australian Embassy or Australian institution or Publication, Radio, TV
Australian Education Centre university
(specify location) (specify) (specify)

Workplace or nominating authority Other
(specify) (specify)

From where did you obtain your application form? (tick box and specify where asked to do so)

ADS website ADS Office AusAID Office

Friend, relative or colleague DEEWR Office GoI State Secretariat Office
Home institution or university AusAID project office
Education Agent (specify)
(specify) (specify)

Workplace or nominating authority Other
(specify) (specify)

24
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 Yes N/A
proof citizenship i.e. KTP or your passport personal information pages Yes N/A
current Curriculum Vitae Yes N/A
official (certified* ) post-secondary and tertiary certificates/degrees Yes N/A
official (certified* ) post-secondary and tertiary transcripts of results Yes N/A
current (original) IELTS or TOEFL English language test results (a test result obtained
in 2011 or 2012 will be considered current). TOEFL prediction test is NOT Yes N/A
accepted.
Masters applicants must also attach certified DIII degree certificate/transcript if using
Yes N/A
DIV or S1 extension certificate/transcript
Doctorate applicants must also attach certified S1 degree certificate/transcript Yes N/A
academic reference from S2 supervisor for Doctorate candidates Yes N/A
Doctorate and those Masters applicants whose study will include at least fifty percent
Yes N/A
research must fill the research proposal details on page 15 of this application form

Additional Documents: (Optional)

Applicants must provide the following documents if they are selected for an interview.
recent photograph (3 x 4) Yes N/A
official (certified* ) English translations of post-secondary and tertiary
Yes N/A
certificates/degrees
official (certified* ) English translations of post-secondary and tertiary transcripts of
Yes N/A
results
references from S1 supervisor for Masters candidates (if available) Yes N/A
list of relevant publications, unpublished theses (for research applicants) Yes N/A
statement from university that English is a language of instruction (if applicable) Yes N/A
relevant correspondence with an Australian university (if available). Yes N/A
official (certified*) English translations of birth certificate Yes N/A
IMPORTANT:
Attach only certified copies of documents. DO NOT attach original documents.
Application forms and documents will not be returned.

25
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 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

26
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)
In-Indonesia Stipend for the period from the commencement of Pre-Course English to the date of awardee
mobilisation. This does not apply to any deferral period.
Medical examination and x-ray costs in order to comply with Student Visa requirements
AusAID Student Visa and Student Dependant Visa
Outward Airfare (economy- one way) from the airport closest to the awardees home location to the
international airport closest to the Australian university selected for study by the awardee
Overseas Student Health Cover (OSHC) - awardee only (awardees are required to maintain OSHC for any
accompanying family in order to satisfy visa requirements).
Establishment Allowance payable into the awardees bank account after arrival in Australia
Contribution to Living Expenses (in Australia Stipend) - payment of a fortnightly contribution to living
expenses (CLE).
Introductory Academic Program (IAP) for a period of 4-6 weeks undertaken prior to the commencement of
Masters or PhD studies
Masters OR PhD Tuition Fees including all compulsory fees for the course in which the awardee is accepted
into
Supplementary Academic Support - provided where it is deemed essential to assist awardees to pass course
subjects.
Fieldwork - holders of a scholarship where research comprises at least 50 percent of the program may receive
a return economy class airfare to Indonesia to undertake essential fieldwork.
Reunion Airfare - is available to a single awardee 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.
Homeward Airfare (economy- one way) from the international airport closest to the Australian university
selected for study by the awardee to the airport closest to the awardees home location.

Your university will provide for:

instruction and facilities necessary to complete the specified course
appropriate academic and welfare support for the duration of your studies
airport reception and temporary accommodation arrangements on arrival in Australia.

23. Nominating Agency Declaration - required for Public sector applicants only*

27
(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 and approval from Bupati or Governor (or representative) where necessary.)
Please note that your signature on this form signifies your agreement to the following:
to release the applicant from work duties while he/she attends English for academic training. This training is full-
time and compulsory
to release the applicant from work duties after English for academic training to study in Australia, and 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 Mayjend HM. Ryacudu General Hospital, Kotabumi, North Lampung
Name of Applicant Mr. Bayu Anggileo Pramesona
Applicants Position title Staff of Nursing Services Departement
Applicants Level of position
in organisation structure III/b Date commenced 1/ 3/ 2009
(eg. Echelon and Golongan)
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*

28
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

/ /
Mr. BAYU ANGGGILEO PRAMESONA
25. Ministry of State Secretariat of the Republic of Indonesia use only

29
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

/ /

30