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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*
Mr Mrs Ms Miss Dr
Other(Please specify)
Given name* KTUT RENTYASTI
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.
Family names* PALUPI
Date of birth* ##/ ##/ #### dd/mm/yyyy Gender* Male Female
Place of birth*
(State/province)
YOGYAKARTA Ethnic group? BALINESE
Which country are you living in now?* INDONESIA
Have you applied, or are you intending to apply, for permanent
residency or citizenship in Australia or New Zealand?*
Yes No
National Identity Number
(KTP No.)

Passport no.
(provide if you have a
passport).*

Issue date 9/ 11/ 2007

Expiry date 9/ 11/ 2012

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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*
Address line 2
Address line 3
Town/City*


State/Province* D. I. YOGYAKARTA Postal code (if any) 55282
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.
Mobile no. Fax no. (if any)
Email 1
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* CENTER FOR TROPICAL MEDICINE, GADJAH MADA UNIVERSITY
Address line 2 JL. TEKNIKA UTARA, BAREK
Address line 3
Town/City* YOGYAKARTA
State/Province* D.I. YOGYAKARTA Postal code (if any) 55281
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* I MADE ANDI
Provide family name and other names as shown in your spouses
birth certificate, passport or other official identification document*
Family names* ARSANA
Date of birth* 0/ 0/ 0 dd/mm/yyyy Gender* Male Female
Passport no.
Provide if spouse
has a passport.*

Issue date 19/ 11/ 2008
Expiry Date 19/ 11/ 2012
Country of
citizenship
INDONESIA
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 ARSANA
Given names PUTU AMBALITA PITALOKA
Date of birth / / dd/mm/yyyy Gender Male Female
Country of citizenship INDONESIA
Passport no.
Provide if child has a
passport.*

Issue date / /
Expiry date / /

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.
Provide if child has a
passport.*

Issue date / /
Expiry date / /

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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.
Provide if child has a
passport.*

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.
Title*
Mr Mrs Ms Miss Dr
Other Please specify
Family name* ARSANA
Relationship to
you*
HUSBAND
Given name* I MADE ANDI Gender* Male Female
Home phone* Work phone
Mobile phone Fax (if any)
Email 1 MADEANDI@UGM.AC.ID
Email 2 MADEANDI@GADJAHMADA.EDU
Address line 1*
Address line 2
Address line 3
Town/City*


State/Province* D. I. YOGYAKARTA Postal code (if any) 55282
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
ADVANCED COURSE ON IMMUNOLOGY, VACCINOLOGY AND BIOTECHNOLOGY APPLIED TO
TUBERCULOSIS
Start date 11 OCT End date 25-11-2010 Country SWITZERLAND, BELGIUM
Qualification (if applicable)
University UNIVERSITY OF LAUSANNE, ITM ANTWERP

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Previous scholarships continued
2. Scholarship/fellowship title
Start date End date
Qualification (if applicable)
University

7. Scholarship applications
Have you previously applied for an AusAID scholarship but were
unsuccessful?*
Yes No
If "Yes" how many times have you previously applied for ADS?
2
Have you previously been interviewed by ADS?* Yes No
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
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



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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 study*
(You will not be allowed to
upgrade your course from the
level at which you are first
placed).
Masters

Doctorate (PhD)
Type of study* (Masters
coursework program can contain a
research project up to 30% of the
Masters. Candidate decide the topic
during course)
Coursework
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 (Please tick one box only).
If necessary, you may nominate another Field of Study in 'other' (Please tick other and provide detail).
Australia
Indonesia
Partnership
Priority
Development
Areas (PDA)*

Sustainable Growth
and Economic
Management

Democracy Justice
and Good
Governance

Investing in People



Safety and Peace



Description
of PDA
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.
Strengthening the
capacity, accountability
and responsiveness of
legal, democratic and
oversight institutions, and
improving local
government and public
financial management.

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.

Australia
Indonesia
Partnership
Priority
Fields of
Study (PFS)*
Natural Resource
Management
Agriculture
Aquaculture/fisheries
Forestry
Climate Change
Economics
Infrastructure
Planning
Water and Sanitation
Rural Growth
Small and medium
enterprise
development
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
Conflict Resolution
Disaster Prevention and
Management
Transport Safety
Transnational Crime
Prevention
Development Studies
International Studies
Other, please specify:

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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.
1. I have collected sufficient information from website of relevant universities in Australia (University of
Wollongong and University of New South Wales), especially regarding my area of studies. I have also been
reading relevant publications (journal, conference papers) regarding my area of studies.
2. My husband is an Australian institution alumnus and I have discussed my plan with him and he has provided
me with relevant information regarding academic life in Australian institutions.
3. I have discussed with the director of collaboration and research unit in center for tropical medicine, Gadjah
Mada University, where I'm currently working, that study in Public Health (PH) specially in epidemiology of
tropical disease will be an advantage for our institution to develop more health research in Indonesia. He
supports me to apply for the study in Australia, as one of the best places for study of PH
4. I am in touch with current Indonesian students in Australia so I can have updated information that I could not
find from other formal sources. In addition I have lived in Sydney and Wollongong and I am maintaining my
communcation with friends living in both cities, which I believe will be an advantage if I return to Australia for
study.
5. When I wasn in Sydney and Wollongong, I was also involved in cultural activities of the Indonesian Students
Asscotiation and I ma maintaining contact with the organisation until now.
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*
MASTER OF PUBLIC HEALTH (IN INFECTIOUS DISEASE EPIDEMIOLOGY AND
CONTROL)
Course title or particular focus
area within your identified
proposed Field of Study.*

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CRICOS code (if applicable)* 008969M
Australian University
(if applicable)
UNIVERSITY OF NEW SOUTH
WALES
Course duration (weeks)
(if applicable)
52
Minimum English
language proficiency
required for the course
(IELTS) (if applicable)



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Proposed preferences continued
Preference 2*
MASTER OF PUBLIC HEALTH
Course title or particular focus
area within your identified
proposed Field of Study.*
CRICOS code (if applicable)* 009245F
Australian University
(if applicable)
UNIVERSITY OF WOLLONGONG
Course duration (weeks)
(if applicable)
52
Minimum English
language proficiency
required for the course
(IELTS) (if applicable)
6.5

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 any relevant correspondence with Australian universities.
Yes No
Are there any special subjects or skills development that you would like to include
in your choice?
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).




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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)
Lihat contoh proposal riset di http://madeandi.com/ads2013/



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)



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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)


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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* MEDICAL DOCTOR
Level of study*
Secondary (High School) Vocational, Technical
( DIII or DIV )

Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university* GADJAH MADA UNIVERSITY
State/Province D. I. YOGYAKARTA Country* INDONESIA
Language of instruction* BAHASA INDONESIA Start date * 20/ 8/ 2001
GPA (if applicable) Obtained 3.## / Max 4.0 End date* 8/ 11/ 2003
Status Complete Pending results Incomplete

2. Qualification name* BACHELOR OF MEDICINE
Level of study*
Secondary (High School) Vocational, Technical
( DIII or DIV )

Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university* GADJAH MADA UNIVERSITY
State/Province D. I. YOGYAKARTA Country* INDONESIA
Language of instruction* BAHASA INDONESIA Start date* 20/ 8/ 1997
GPA (if applicable) Obtained 3.## / Max 4.00 End date* 19/ 8/ 2001
Status Complete Pending results Incomplete

3. Qualification name SMA
Level of study
Secondary (High School) Vocational, Technical
( DIII or DIV )

Undergraduate (S1) Postgraduate (S2 or S3 )
Name of university SMA 3 YOGYAKARTA
State/Province D. I . YOGYAKARTA Country INDONESIA
Language of instruction BAHASA INDONESIA Start date / 7/ 1994
GPA (if applicable) Obtained / Max End date / 7/ 1997
Status 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 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.
IELTS or TOEFL)
IELTS
Date test
taken
14/05/2011

Overall
score
6.0
Test Centre/location IALF/YOGYAKARTA Phone Website http://ialf.edu
If `No, when do you expect to complete the
test?
/ / Test name
KTUT RENTYASTI
PALUPI

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

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 / /



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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* RESEARCH ASSISTANT
Organisation* CENTER FOR TROPICAL MEDICINE, GADJAH MADA UNIVERSITY

Level of position in
organisation structure
(eg. Echelon and Golongan)
Date commenced* 23/ 8/ 2011
Sector/organisation type
Government/Public NGO /Civil Society Private
Briefly describe the work of
your organisation and the
service it provides.
THIS RESEACH AND COLLABORATION UNIT IS PART OF THE CENTER FOR
TROPICAL MEDICINE, GADJAH MADA UNIVERSITY, THE WORKS OF WHICH FOCUS
ON RESEARCH OF TROPICAL DISEASE, IE: TUBERCULOSIS, DENGUE, MALARIA,
ETC. THE RESEARCH IS IN COLLABORATION WITH THE INSTITUTE OF TROPICAL
MEDICINE, ANTWERP BELGIUM, WHO/TDR, NATIONAL TB PROGRAM, KNCV, ETC.
THE CENTER HAS BEEN SELLECTED AS A REGIONAL TRAINING CENTER (RTC) OF
WHO/TDR SINCE 2009. THE ACTIVITITIES OF RTC ARE PROVIDING TRAINING
NATIONALLY AND REGIONALLY FOR GOOD CLINICAL PACTICES, GOOD CLINICAL
LABORATORY PRACTICE, EFFECTIVE PROJECT PLANNING FOR BIOMEDICAL
RESEARCH, ETC.THIS CENTER HAS ALSO BEEN INVOLVED IN TBCTA (TB
COALITION FOR TECHNICAL ASSISTANT) FOR SEVERAL YEARS.

Briefly describe your current
duties and responsibilities
(max 500 characters, approx
80-100 words limit)
AS A RESEARCH ASSISTANT FOR RESEARCH ON EVALUATION OF NEW METHOD
OF TUBERCULOSIS DIAGNOSIS, MY RESPONSIBILITES ARE:
1. COORDINATING LABORATORY ACTIVITIES AND SUPPLIES
2. CONDUCTING NEW METHOD, THIN LAYER AGAR IN THE LAB AND INTERPRET
THE RESULTS
3. REVIEWING DATA
4. ASSISTING IN DATA ENTRY AND DATA ANALYSIS
5. ASSISTING IN REPORT WRITING







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)
MY FUTURE ROLE IS TO DEVELOP MORE HEALTH RESEARCH ESPECIALLY IN THE
AREA OF PUBLIC HEALTH AND INFECTIOUS DISEASE, USING NEW METHOD AND
APPROACH. ADEQUATE BASIC KNOWLEDGE IN EPIDEMIOLOGY WILL SUPPORT
MY RESEARCH TO BETTER UNDERSTAND HEALTH PROBLEMS IN THE
COMMUNITY. FURTHERMORE, MY ROLE IS TO FACILITATE THE PROVISION OF
RESEARCH RESULT TO BE USED AS EVIDENCE BASE FOR GOVERNMENT IN THE
MAKING OF HEALTH POLICIES.
IN ADDITION, I WILL BE MORE INVOLVED IN TUTORIAL AND TEACHING ACTIVITIES
ON PUBLIC HEALTH TO SHARE MY KNOWLEDGE TO THE STUDENTS.










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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)
TASKS:
1. TO DEVELOP MORE RESEARCH IN PUBLIC HELATH AREA SPESIFICALLY FOR
TROPICAL DISEASES WITH NEW/UNCONVENTIONAL METHOD/APPROACH
2. TO BE A TUTOR FOR TEACHING AND TRAINING IN PUBLIC HEALTH
3. TO MAINTAIN GOOD COMMUNICATION AND RELATIONSHIP WITH PARTNERS,
WHO, NTP, UNIVERSITIES, RESEARCH CENTER IN ITM, BELGIUM












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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 RESEARCH ASSISTANT
Organisation
PMPK
Start date 1/ 1/ 2008 End date 1/ 8/ 2008
Duties/responsibilities
(max 500 characters, approx
80-100 words limit)
RESEARCH PROJECT: ASSESSMENT OF HOSPITAL DOTS STRATEGY
IMPLEMENTATION
A. AS A FIELD COORDINATOR ON DATA COLLECTION IN 5 PROVINCES (WEST
SUMATERA, SOUTH SUMATERA, SOUTH KALIMANTAN, BALI, AND PAPUA
PROVINCES)
B. TO ASSIST IN DEVELOPMENT OF PROPOSAL, BUDGETING AND RESEARCH
INSTRUMENTS
C.TO ASSIST IN COMMUNICATION WITH RELEVANT PARTIES IN PROVINCES, NTP
AND WHO











2. Previous position
Position title RESEARCH ASSISTAN FOR TB PROGRAM
Start date 1/ 12/ 2006 End date 31/ 12/ 2007
Organisation
WORLD HEALTH ORGANIZATION (WHO), JAKARTA
Duties/responsibilities
(max 500 characters,
approx 100 words limit)
RESEARCH PROJECTS:TUBERCULIN SURVEY FOR ESTIMATING ANNUAL RISK
TRANSMISSION OF INFECTION IN CENTRAL JAVA AND EAST NUSA TENGGARA IN
COLLABORATION WITH UNIVERSTAS INDONESIA
ESTABLISHMENT OF SENTINEL SITE FOR SPECIAL SURVEILLANCE OF TB
MORTALITY IN 4 PROVINCES IN COLLABORATION WITH NIHRD MOH
ASSESSMENT OF HOSPITAL DOTS IMPLEMENTATION IN COLLABORATION WITH
GMU.

A. PROVIDING SUPPORT IN THE MANAGEMENT OF RESEARCH PROJECTS UNDER
DFID (DEPARTMENT FOR INTERNATIONAL DEVELOPMENT) FUNDS.
B. ASSIST IN PLANNING, BUDGETING, MONITORING, TRACKING, DATA ANALYSIS
AND REPORTING OF THE RESEARCH STUDIES.
C. ASSIST IN PLANNING AND IMPLEMENTATION OF TRAINING ACTIVITIES UNDER
DFID
B. ENSURING CLOSE COLLABORATION WITH NATIONAL RESEARCH PARTNERS AND
TECHNICAL AGENCIES.





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17. Interview Centre *
Please tick your preferred interview center. (Please note Your choice is not guaranteed.)
Jakarta
Yogyakarta
Surabaya
Denpasar
Medan
Padang
Balikpapan/Banjarmasin
Jayapura
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?*
AUSTRALIA HAS AN ADVANCED EDUCATION SYSTEM WHICH IS COMPARABLE TO THAT IN THE US AND EUROPE. AUSTRALIA
HAS REMARKABLE ACHIEVEMENT IN RESEARCH WITH A NOBEL PRIZE IN 2005. BY OBSERVING ONLINE LIBRARIES OF VARIOUS
UNIVERSITIES IN AUSTRALIA AND GATHERING INFORMATION FROM AUSTRALIAN ALUMNI, I KNOW THAT AUSTRALIAN
UNIVERSITIES PROVIDE GOOD STUDY RESOURCES, WHICH IS EVEN BETTER, TO CERTAIN EXTENT, COMPARED TO THAT IN
EUROPE.

AUSTRALIA AND INDONESIA ARE GEOGRAPHICALLY AND POLITICALLY CLOSE SO THAT I CAN EXPECT MORE SUPPORT FROM
BOTH COUNTRIES WHEN I STUDY IN AUSTRALIA. RELATIVELY CLOSE DISTANCE WILL FACILITATE FUTURE COLLABORATION SO
MY STUDY IN AUSTRALIA IS NOT A TERMINAL POINT BUT A STARTING POINT FOR FUTURE ENGAGEMENT.






2. What skills and knowledge do you hope to gain and how do you propose to use them?*
FIRSTLY, I WOULD LiKE TO ENHANCE MY RESEARCH SKILL THAT I WILL USE IN MY RESEARCH IN THE CENTER FOR TROPICAL
DISEASE (MICROBIOLOGY LABORATORY), GADJAHMADA UNIVERSITY. IN ADDITION, I ALSO WANT TO GAIN KNOWLEDGE IN
STATISTICAL ANALYSIS, MANAGEMENT AND EPIDEMIOLOGY TO OPTIMISE RESEARCH PROCESS FOR BETTER RESULT.

SECONDLY, I WANT TO GAIN RELEVANT KNOWLEDGE RELATED TO MEDICAL EDUCATION IN AUSTRALIA. IN PARTICULAR I AM
INTERESTED IN KNOWING HOW AUSTRALIAN INSTITUTIONS PROVIDE EDUCATION SERVICE TO STUDENTS AND HOW THIS CAN
BE USED TO ENHANCE WHAT WE CURRENTLY HAVE IN MY INSTITUTION. BY OBSERVING THIS, I WILL MANAGE TO UNDERSTAND
WHAT TO MAINTAIN AND WHAT TO IMPROVE FOR BETTER RESEARCH AND EDUCATION.
3. How will the proposed training be of benefit to Indonesia?*
HEALTH IS ONE OF THE SECTORS THAT INDONESIA NEEDS TO IMPROVE. THE TRAINING I AM PROPOSING
WILL ENABLE ME TO GAIN MORE KNOWLEDGE AND SKILLS ON PUBLIC HEALTH SECTOR PARTICULARLY IN
RELATION TO TROPICAL/INFECTIOUS DISEASE CONTROL. SINCE INDONESIA IS STILL FACING PUBLIC
HEALTH PROBLEMS FOR EMERGING DISEASE IE TUBERCULOSIS, MALARIA AND THE CURRENT SITUATION
OF HIV/AIDS, MORE RESEARCH NEED TO BE DONE. THE RESULTS WILL PROVIDE EVIDENCE THAT WILL
SUPPORT THE GOVERNMENT AS THE DECISION MAKER FOR HEALTH POLICIES.

INDONESIA, BEING THE LARGEST ARCHIPELAGIC COUNTRY IN THE WORLD, REQUIRES MORE EXPERTS IN
PUBLIC HEALTH TO IIMPLEMENT THE INTERVENTION THROUGH PREVENTION AND TREATMENT OF DISEASE
FOR IMPROVING HEALTH AND QUALITY OF LIFE, AS WELL AS THROUGH SURVEILLANCE OF CASES AND THE
PROMOTION OF HEALTHY BEHAVIORS. THIS WILL STRENGTH THE HEALTH QUALITY IN THE COMMUNITY.







25

Supporting statement continued
4. 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.


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 or to live and undertake studies in Australia?)



26

19. Professional memberships
Professional memberships may include community, cultural, political, scientific, professional and/or educational
associations and organisations.
1. Organisation Name IDI
Highest position held (if any)
Member
Start date
6/ 11/ 2006 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 scholarship recipient Australia Awards website
AusAID or Managing
Contractors Office
Friend, relative or colleague AusAID Website Home institution or university

Australian Embassy or
Australian Education Centre
(specify location)
Australian institution or
university
(specify)
Publication, Radio, TV

(specify)


Workplace or nominating authority
(specify)

Other
(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

Education Agent (specify)

Home institution or university
(specify)

AusAID project office
(specify)


Workplace or nominating authority
(specify)

Other
(specify)


27

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 2010 or 2011 will be considered current). TOEFL prediction test is NOT
accepted.
Yes N/A
Masters applicants must also attach certified DIII degree certificate/transcript if using
DIV or S1 extension certificate/transcript
Yes N/A
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
research must fill the research proposal details on page 15 of this application form
Yes N/A

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
certificates/degrees
Yes N/A
official (certified* ) English translations of post-secondary and tertiary transcripts of
results
Yes N/A
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.



28
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.



29
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 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.


30
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
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 / /

31
24. Applicants authorisation, agreement, declaration and signature*
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

/ /

32
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

/ /