Australia-Malaysia “Towards 2020” Scholarships: Nomination Form 2016

Executive Awards

1.1 NAME (MANDATORY)
Nominee Name:
Title: / Mr / Ms / Other (please specify)
Given names:
Family name:
Date of birth:
1.2 CONTACT DETAILS (MANDATORY)
Street address:
Suburb/Town: / State: / Postcode:
Postal address:
(if the same as your street address, write ‘as above’)
Suburb/Town: / State: / Postcode:
Contact Numbers: / Work: / () / Home: / () / Fax: / ( ) / Mobile:
Email:
1.3 ACADEMIC BACKGROUND (MANDATORY)
1.4 EMPLOYMENT BACKGROUND(MANDATORY)
1.5PROPOSED PROGRAM DESIGN (MANDATORY)
Please ensure that you include the estimated cost of any courses or conferences included in your program design.
1.6CURRENT EMPLOYER SUPPORTING STATEMENT (MANDATORY)
Please provide a letter of support from your current employer.
1.7REFEREES (MANDATORY)
Please provide letters of support from two referees. Referees must include full contact details (name, address, phone, email).
1.8 CERTIFICATION (MANDATORY)
Privacy and Freedom of Information
The information you provide in your funding submission is used when processing and assessing your submission. Summary information provided by all applicants will be stored centrally and will be available to Commonwealth officers and the government on a need-to-know basis. The information you have provided, including personal information, may be disclosed to Commonwealth and State or Territory governments, organisations which are responsible for grants programs, and may be made public through national and local media or via the DFAT or Australian High Commission Kuala Lumpur websites. DFAT may also publish this information, including personal information, in its Annual Report and on the DFAT web site. DFAT will only use and/or disclose personal information in accordance with the Privacy Act 1988. Applicants should also note the provisions of the Freedom of Information Act 1982apply to documents in DFAT’s possession.
I, the undersigned, certify that:
  • I have read the relevant information provided for this applicationand meet the general eligibility criteria.

  • The statements in this application are true to the best of my knowledge and any supporting material is my own work or the work of the persons named in this application.

  • I accept that DFAT and the Australian High Commission Kuala Lumpur (AHCKL) reserves the right to use whatever assessment processes and selection criteria they deem necessary to evaluate this and other applications for fellowship funding

  • I acknowledge that this application will be assessed on its merits, and compared to other applications, and that it may not be funded.

  • I consent to information provided in this application being stored on a central database to which other Commonwealth, State or Territory government agencies may have access.

  • I consent to information provided in this application, other than personal information,being used for training and testing purposes by DFAT/AHCKL staff.

  • If my application is successful, I consent to the media or members of parliament being given information, other than personal information, about the funded project and agree I may be contacted directly by them.

Signature: /  / Date: / / / /
Name in full:

The Australian High Commission Kuala Lumpur (AHCKL) must have a signed copy of your application form on or before the closing date. The signed application form can be submitted to the AHCKL in one of three ways:

  • electronically by email (in word or pdf) to
  • faxed to + 60 32148 0249 (Attn: Damian Hickey) or
  • posted to:Australia-Malaysia Scholarships Towards 2020
    c/o Mr Damian Hickey
    First Secretary
    Australian High Commission
    PO Box 10921
    50730 Kuala Lumpur

It is the applicant’s responsibility to ensure that a signed copy of the application is received by the AHCKL on or before the closing date. Incomplete applications will not be considered.

The closing date for application lodgement is 5:00pm on 18 April 2016.