Australia-Japan Foundation Sir Neil Currie Australian Studies Awards
Early Career Researcher Support: Travel Funds for Conferences
2011-12 APPLICATION FORM
1. DETAILS OF APPLICANT
Please indicate (i.e.,√)
□Dｒ. □Mr.
Status:
□ Single
□Ms.
□Other (pls specify).
□ Married □ De Facto
Surname
Given Names
Roman Alphabet:
Roman Alphabet:
Japanese Kanji:
Japanese Kanji
Permanent Home Address:
Roman Alphabet:
Japanese Kanji: 〒
Phone (Private)
Fax (Private)
Email Address:
Mailing Address: □ Same as above
Roman Alphabet:
Japanese Kanji: 〒
Phone (Business)
Email address at work:
Fax (Business)
Date of Birth (Day/Month/Year)
Place of Birth (City and Country)
Roman Alphabet:
Japanese Kanji:
Country of Residence
Citizenship
Name of Japanese Institution
Roman Alphabet:
Japanese Kanji:
Faculty
Roman Alphabet:
Japanese Kanji:
Department
Major Roman Alphabet:
Japanese Kanji:
Major
Roman Alphabet:
Japanese Kanji:
Current or latest Course of Study
B.A. □ Years……………… Master □ Years.................... PhD □ Years ………………
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Project Title for Sir Neil Currie Award
(Please include the name of conference and/ or symposium you wish to participate and
describe what you aim to achieve through participation)
Pls describe other activities related to above described project (if any).
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Next of Kin: (Name, address, phone/fax and relationship to person to be informed in case of emergency)
Name:
Address:
Roman Alphabet:
Roman Alphabet:
Japanese Kanji:
Japanese Kanji:
Phone/Fax:
Relationship:
ACADEMIC AND PROFESSIONAL BACKGROUND
Please attach a Record of Tertiary Education (in chronological order) and professional
experience (if applicable). Please include details of current responsibilities, course and level.
Academic distinctions, prizes received and other awards
2. DETAILS OF CONFERECE IN AUSTRALIA
Name of conference
Date of conference
Name of organiser:
Department, School or Faculty (if applicable):
Contact Person: □Professor
□ Mr
□ Ms
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Name:
Telephone Number:
Fax Number:
Email:
3. DETAILS OF AWARD PROGRAM
The application must include statements from the Applicant and Host Institution addressing:
From the Applicant:
• Details of proposed program, including details of participating symposium/conference, scope
of your participation, planned activities, timetable, location and contact details in English
• The intended outcome of the program including details of how the program will benefit the
applicant personally and professionally.
• How the program will contribute to strengthening the links between Japan and Australia.
From the Japanese Institution:
• An assessment of the suitability of the Applicant to undertake the program
• Details of any contribution to be provided by the Japanese institution
4. SELECTION CRITERIA
The application should include information to show how the selection criteria have been met:
From the Applicant:
• records/references and details of academic excellence; and
• demonstrated fluency in spoken and written English
From the Japanese Institution:
The Japanese Institution should provide a statement indicating how the following selection
criteria have been met:
• the suitability of the Applicant to undertake the program including details of relevant
communication with the Applicant; and
• the potential of the program to promote Australian Studies in the institution and/or in Japan
to expand the bilateral relationship between the two countries.
5. CHECK LIST
The following documents must be in English or English translations of original documents,
and each document must be a certified as a true copy or translation of the original document.
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Please indicate (i.e., √) that the application supporting documents are attached:
□ Statement from Applicant;
□ Statement from Japanese Institution;
□ Certified copy of current passport showing evidence of citizenship or residence;
□ Records/references and details of academic excellence;
□ Records of fluency in spoken and written English;
□ One separate letters of reference for the Applicant;
□ Academic record endorsed by the relevant Institution, showing the subjects and standards
of pass for each with an explanation of the marking system;
□ A letter from Australian Host Institution and/or organisation representative supporting the
applicant
(While this evidence does not have to be supplied at application, but the applicant must
supply evidence of such acceptance as soon as possible. Please advise us if it is the
separate supply. An Award will not be made until the evidence of an offer is provided.)
Please state the dates the Award program will be commenced and finished:
from ......... / ......... / .........
day month year
to ......... / ......... / .........
day month year
You must include the original and two copies of the completed Application Form. In
total, three sets of the application should be attached.
6. BUDGET SPECIFIC TO THIS APPLICATION
The award budget applied for will be used in accordance with details provided in the following
table:
Budget Item
International economy class airfare
Japan-Australia (direct route)
Domestic travel costs
Living and Accommodation costs while in
Australia
Administration/enrollement costs to the
receiving institution
Health insurance costs (Overseas student
health cover)
Other costs (Please attach details by item
and cost)
TOTAL FUNDING SOUGHT FROM AJF
Amount AUD
Date funds are required
Where the applicant seeks additional funding or support, or where this funding or support is
being provided by the Japanese institution, a proposed budget should be attached.
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Any cost incurred beyond the value of the award is the responsibility of Awardee.
Please note that the award is ONLY payable in Japanese Yen at a value of Yen against
AUD$ at the time of payment.
7. TERMS AND CONDITIONS
The Terms and Conditions for this award are set out in the brochure and the Application Form.
□ the Japanese institution is/ has been made aware of its responsibilities.
8. PRIVACY NOTICE
Before this form is submitted the Applicant must be informed of the privacy notice below and
the declaration must be completed.
The Australia-Japan Foundation is bound by the provisions of the Privacy Act 1988. The
information collected in this form (and any attachments) will be used for the purposes of
assessing the Applicant's eligibility for this award. The information will be passed to a
Selection Committee who will make a recommendation to the Foundation. Information
provided by the Applicant as part of, or relating to, this application may be disclosed to the
proposed Host Institution. Where personal information is sent out of Australia, other than to
Australian Overseas Missions, it no longer has the protection afforded it by Australian law.
Please indicate (i.e. √).
□ the applicant is/has been made aware of the privacy notice.
9. DECLARATION BY AUSTRALIAN HOST INSTITUTION REPRESENTATIVE
I declare that I have consulted (name of Applicant) .......................... and I believe the
Applicant is capable of undertaking the proposed program within the duration of the award.
Name of Host Institution in Australia:
Name and position: □Professor
□Mr
□Ms
Signature: ........................................... Date: ...... /............ / ..............
If the Applicant has received a letter from the Australian host institution supporting the
application and acknowledging that they are capable of undertaking the proposed program,
this can be ignored.
10. DECLARATION BY APPLICANT
I declare that I am a citizen of, and/or normally reside in Japan and that the statements made
in this application are, to the best of my belief, true, complete and correct.
If granted an Award I undertake to observe all the conditions of the Award.
ECRS7/8
Name of Applicant:
Signature: ........................................... Date: ...... /............ / ..............
Where did you get the Sir Neil Currie Award information from?
………………………………………………………………………………
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