2016
Endeavour Referee
Report
Nomination
Form
• Nominations
to be for
made
the applicants
host organisation(s).
The are
person
completing
form reports
must hold
senior
The selectionare
process
theby
Endeavour
Scholarships
and Fellowships
merit-based
andthis
referee
do anot
guarantee
an offer.within the host organisation.
position
Referee
reports
received
the closingScholarships
date will not and
be considered.
•• The
selection
process
for after
the Endeavour
Fellowships are merit-based and nominations do not guarantee
offer. returned
Nominations
received
the closing
date
will not
considered.
• an
Reports
directly
to theafter
department
will be
treated
asbe
confidential
and will only be made available to the selection
panel
and
administrators.
• Nomination forms returned directly to the department will be treated as confidential and will only be made available to the
• Endeavour
Referees may
be contacted
by the
selection panel during the selection process.
selection
panel and
administrators.
1. APPLICANT
Title: DETAILS
PL
E
• Information
for potential host organisations can be found on the Endeavour website.
1. APPLICANT
DETAILS
First Name:
Mr
Title: Mr
The Endeavour category the applicant is applying for:
Hiro
First Name: Hiro
Last Name:
Suzuki
Last Name: Suzuki
Research Fellowship (including Research Fellowship for
Indigenous Australians and QE II)
Application ID:
(If known)
ERF_PDR_134977_2015
ERF_PDR_134977_2015
ID:DETAILS
2.Application
REFEREE
Title:
2. NOMINATING ORGANISATION DETAILS
Title:
Position Held:
Mr
Mr
Last Name:
Organisation:
Michael
First Phone:
Name: +Michael
(Please include country and area codes)
Senior Researcher
Researcher
PositionEmail:
Held: Senior
Postal
2Address
8435 9946
9946
61 2
8435
Phone: + 61
Address Line 1:
(Please include country and area codes)
Address Line 2:
Postal Address
City/Suburb:
Address
Line 1: 38
38 University
University Road
Road
Postcode:
Address Line 2:
City/Suburb:
Postcode:
Executive Fellowship
Postgraduate Scholarship (Australian only)
EX
AM
First Name:
or
The
The University
University of
of Sydney
Sydney
Relationship to applicant
Sydney
Sydney
2006
2006
Last Mobile:
Name:
Organisation:
Email:
Smith
Smith
The
University of
of Sydney
The University
Sydney
[email protected]
[email protected]
State/Province:
Country:
State/Province:
Country:
Length of relationship
NSW
NSW
Australia
Australia
Years
Months
3. APPLICANT EVALUATION
Have you discussed the proposed dates with the applicant?
Please evaluate the applicant against the criteria below, in terms of your experience.
Yes 5% = Excellent, Top 10%
No = Very Good, etc.)
(Example: Top
Unable to
Recipients must commence their proposed program between
1 January and
30 NovemberGood
of the roundVery
year.Good
Please check
the Endeavour
website
Poor
Average
Excellent
comment
for minimum and maximum durations. http://internationaleducation.gov.au/endeavour
Academic/professional achievement
Leadership qualities
Personal integrity
Capacity to communicate and relate well to others
Resourcefulness and initiative
Emotional maturity
Adaptability to new situations
Potential for future contribution in field of study
3
1 of 2
Endeavour Nomination Form
3. PROPOSED PROGRAM
Please provide a brief summary of the proposed program (maximum 300 words)
PL
E
The
applicants proposed
proposed program
The applicants
program will.......
will.......
How will the proposed program build or improve the linkages between the home and host organisations? (maximum 100 words)
EX
AM
The applicants
program will
will improve
linkages between.......
The
applicants proposed
proposed program
improve the
the linkages
between.......
Why has the organisation chosen to nominate this applicant and what benefits will be gained from the proposed program?
(maximum 100 words)
The organisation
The
organisation has
has decided
decided to
to nominate
nominate this
this applicant
applicant because
because of.........
of.........
2 of 3
Endeavour Nomination Form
3. PROPOSED PROGRAM (continued)
Is the applicant’s language ability suitable to undertake the proposed program at your organisation?
Yes
No
Please note, if this box is ticked the applicant will be deemed ineligible and their application will
not be considered further.
Signature
Michael Smith
Michael
Smith
Date (dd/mm/yyyy)
03/06/2016
03/06/2016
Print Form
* By typing your name into this box, it is considered that you have signed this form and all the information is true and correct
(An electronic signature is not required).
Privacy Act 1988
PL
E
The department and its contractors are bound by the provisions of the Privacy Act 1988 (Privacy Act). Schedule 1 of the Privacy Act outlines the Australian
Privacy Principles (APPs), which prescribe the rules for handling personal information, including sensitive information.
Personal information (including sensitive information) provided to the department in relation to applications under the Endeavour Scholarships and
Fellowships will only be used by the department for the following purposes (‘the Purposes’):
• assessing applications, and
• administering the Endeavour Scholarships and Fellowships.
The department may disclose personal information it holds in relation to applications under the Endeavour Scholarships and Fellowships for the
Purposes listed above to the following recipients:
• Australian Government Departments and agencies, including but not limited to Austrade, the Department of Foreign Affairs and Trade,
the Department of Immigration and Border Protection, the Australian Federal Police and the Department of Prime Minister and Cabinet
• Australian Parliamentarians and Parliamentary committees, and
• the department’s contractors and agents located in Australia and/or overseas.
By completing and submitting this form, you agree that APP 8.1 will not apply in the event that your Personal Information is disclosed by the department to
an individual or party located overseas. You also understand that an individual or party located overseas will not be accountable under the Privacy Act and
as a result you will not be able to seek redress under the Privacy Act for any privacy breaches committed by the individual or parties located overseas.
EX
AM
For information on the department’s privacy policy, including information on how the department handles personal information, how someone can access
or correct personal information, or how to make a complaint, go to www.education.gov.au/privacy or request a copy of the privacy policy from
[email protected].
3 of 3