FACULTY OF ARTS AND
SOCIAL SCIENCES
Return address:
Faculty of Arts and Social Sciences
Lombok Applications
University of the Sunshine Coast
Maroochydore DC QLD 4558
APPLICATION FOR AWARD STUDY
IN-COUNTRY INDONESIAN LANGUAGE PROGRAM
Application Deadline for Study in January 2008: 31 October 2008
Personal Details
Student ID
Contact Telephone
Numbers:
Family Name / Surname
Given Name/s
Business Hours
After Hours / Home
Mobile
Fax
Mailing Address
Postcode
Program of Study
University Email Address
Other Email Address
Emergency Contact Details
Contact 1 / Next of Kin
Name
Contact Telephone
Numbers:
Relationship
Business Hours
After Hours / Home
Mobile
Fax
Mailing Address
Postcode
Email Address
Contact 2 / Next of Kin 2
Name
Contact Telephone
Numbers:
Relationship
Business Hours
After Hours / Home
Mobile
Fax
Mailing Address
Postcode
Email Address
Please attach any medical information the program coordinators should know. It will be treated with strictest confidence.
Additional Personal Details
Date of Birth
Passport Number
Place of Birth
Dates of Issue and Expiry
Nationality
Place of Issue
Study Details
Which Universitas Mataram unit(s) are you applying for? (Please tick one or two boxes)
Indonesian Language 1
Indonesian Language 2
Indonesian Language 3
Indonesian Language 4
Indonesian Language 5
Indonesian Language 6
Indonesian Language 7
Indonesian Language 8
What is the highest level of Indonesian Language study you have undertaken previously towards a degree, if any?
Unit Code:
Title:
Have you undertaken any other Indonesian Language courses?
University:
Yes
No
NOTE:
If you are seeking credit for this in-country study at an Australian University, It is your responsibility to seek the agreement of your
Indonesian lecturer and Course Advisor at your University before undertaking the course. Refer them to the website or provide
contact details for Dr Philip Mahnken at USC if required. Although we will try to place you according to evidence provided and a
placement test, USC accepts no responsibility if you undertake a level of study that is inappropriate for your progress in another
Degree Program. If concerned approach the Resident Director in the first week.
Medical and Travel Details
It is a requirement of participation that ALL Students have Comprehensive Medical and Travel Insurance. In case we need to contact
them for you, please note here the following details.
Name of Medical Insurer
Contact Details
Policy Number
And/Or
Name of Travel Insurer
Contact Details
Policy Number
Do you have the 24 hour Emergency Phone Number for your Travel Agent? If so please complete their details below
Travel Agent Name
Travel Agent Emergency Phone
Number
Accommodation Details
All students will be placed in family homestays. Please indicate any special needs to do with accommodation, e.g. vegetarian,
religious issues, married /coming with partner, medical issues, etc
Level 3 – 6
Tulislah 100 kata tentang mengapa Anda mau belajar bahasa Indonesia di Pusat Bahasa, Universitas Mataram, Lombok. Apa
harapan dan tujuan Anda?
Write 100 words in Indonesian about why you wish to study at the Language Centre, University of Mataram, Lombok. What are your
hopes and goals?
Tingkat 7 dan 8
Anda akan perlu mengadakan wawancara dengan warga Lombok dan menulis laporan.
Tulislah 100 kata tentang tema penelitian yang ingin Anda pelajari di Lombok, misalnya
Peran wanita dan gender
Pendidikan dan sekolah
Pembangunan dan pengembangan kapasitas
Seni dan budaya
Bisnis, perdagangan, pekerjaan
Hukum dan pidana
Politik dan desentralisasi
Admissions Requirements
Please ensure that you complete all forms relevant to your enrolment application. This form alone is not sufficient for completing
your enrolment in a course or unit of study. USC Students must complete an Enrolment form that you can collect from the
Faculty of Arts and Social Sciences Administration Office
Checklist
Student
1
USC STUDENTS – I Have completed and signed the Change of Enrolment Form (listing INT282 or INT283)
and lodged with USC Faculty of Arts and Social Sciences
2
CROSS INSTITUTIONAL STUDENTS – I have completed and signed the Cross Institutional Enrolment
Form (listing INT282 or INT283) and lodged with USC Faculty of Arts and Social Sciences.
3
CDU ,UNE & UTAS STUDENTS – I have completed the necessary enrolment forms with my Home
University
4
I have completed and signed the HECS Payment Option form (from any University Student Administration),
provided my Tax File Number and indicated which Payment Option I have chosen.
5
I will be 18 years of age or over at commencement of the course.
7
My Social Cultural Visa Application has been sent to Canberra or other Consulate
8
I have booked a return airfare
9
I have planned how I will take money to Indonesia. I have extra available on bank/credit card in case of
emergency
10
I have made a doctor’s appointment for a check up and travel advice.
11
I have prepared a confidential brief on any medical conditions that I may have, to take to Indonesia for the
resident staff member.
12
13
Admin
I have read the DFAT Travel Warning and Smart Travel advice.
http://www.smartraveler.gov.au/zw-cgi/view/Advice/Indonesia
I have read the USC Code of Conduct (attached) and understand my responsibilities as a USC
Student? Code of conduct also at:
http://www.usc.edu.au/University/AbouttheUniversity/Governance/Policies/StudentRelated/Conduct.htm
If I do not comply with the Code of Conduct and advice of the Resident Director and Indonesian Course
Coordinator, the responsibility for my welfare is automatically devolved to myself. I understand and agree.
14
Every excursion and every daily walk has its emergency routine and meeting place (“We meet here at this
time”). Every student will be issued contact procedures for every excursion, phone number of University
and Security people in Lombok so there is a safety contact in case of problem. I understand and agree
15
Do you have a strong money belt or bag that will give pick-pocketers a hard time getting your wallet,
passport and air tickets? When at the beach, you may need a waterproof container. Never leave valuables
under a towel or buried in the sand.
16
I will bring an extra photo for the Language Centre pinboard at Universitas Mataram
17
I have checked the Australian Embassy website http://www.austembjak.or.id/ registered my presence in
Indonesia www.orao.dfat.gov.au and signed up for email bulletins.
18
My Family details in Australia [are recorded by the Faculty of Arts and Social Sciences at the University of
the Sunshine Coast, to the Resident Director and to the staff of Pusat Bahasa, Universitas Mataram.]
View the privacy declaration at http://www.usc.edu.au/privacyplan
Declaration
I hereby declare that the information I have supplied on this form is, to the best of my knowledge, complete and correct. I undertake
to pay the prescribed fees and incidental charges within the time allowed by the University for such payment.
I hereby declare that I have read and understand the Commonwealth Government’s Travel Warning for Indonesia at
http://www.smartraveler.gov.au/zw-cgi/view/Advice/Indonesia and that I am going voluntarily to Indonesia, not as a requirement
of the university. I declare that I have fully and frankly informed the program coordinators of any serious known or potential personal
health issues. I declare that I will respect the lawful authority of the Australian and Indonesian lecturers and engage in no behaviour,
which puts the welfare, learning or good standing of other students at risk. I declare that I have purchased my own comprehensive
travel insurance.
Signature:
Date:
Further Information
In Indonesia your mobile phone number and full accommodation details will also need to be recorded by the Resident Director, the
Language centre and your home university contact office. Yes I agree.
Make sure that you have obtained all the staff and emergency contact details in Lombok, and Australia for USC prior to departure
refer to number 15 in the checklilst.
Dr Pam Allen will be in Lombok from 30th December 2008 working on final preparations for the program. Those who wish to contact
her in Lombok can email pallen@utas.edu.au go to Hotel Airlangga go to the University Pusat Bahasa or telephone 0370 622 503.
You can ask about course materials, homestays, security arrangements etc.
Dr Richard Curtis from Charles Darwin University will be Resident Director for the first half of the second three weeks. He will be
arriving in Lombok on the 23rd January 2009, Email richard.curtis@cdu.edu.au
Mr Steve Miller from the University of New England will be Resident Director for the second half of the second three weeks. He will
be arriving in Lombok on the 23rd January 2009, Email smiller6@une.edu.au
Print this document and check and re-check you have done everything.
The information page is constantly being updated at http://intranet.usc.edu.au/wacana/lombok
Approval to Undertake In Country Study
(All Students) This section must be signed off from the In-Country Study Coordinator – Phillip Mahnken
Period of in country study:
to
The in-country study has been arranged with the following organisation:
Organisation Name:
In-Country Study Coordinator
Approved
Yes
No
(USC Students) This section must be signed off from your Program Advisor
The in country study is
Assessed
Course Code:
Program Advisor Signature
Additional comments:
Not Assessed
Course Title:
(Please tick one)