2017
2016
Endeavour Referee
Report
Application
Form
PL
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•Submitting
The selection process
for theApplication
Endeavour Scholarships and Fellowships are merit-based and referee reports do not guarantee
Your
an
an offer.
offer.
Please ensure that you have read the Endeavour Scholarships and Fellowships Applicant Guidelines available on the
•Endeavour
Referee reports
after the closing
dateReturn
will notyour
be considered.
websitereceived
before completing
this form.
application forms and the required supporting documentation to:
• Reports
returned
directly
to
the
department
will
be
treated
as confidential and will only be made available to the selection
Endeavour Management Team
panel and administrators.
Australian Government Department of Education and Training
• Referees may be contacted by the selection panel during the selection process.
International Group, GPO Box 9880
1.
DETAILS
1. APPLICANT
APPLICANTCanberra
DETAILS
ACT 2601, AUSTRALIA
Incomplete
or late applications will not be accepted
Mr
Title:
First
First Name:
Name: Hiro
Last
Last Name:
Name: Suzuki
1. PERSONAL DETAILS
The Endeavour
Endeavour category
category the
the applicant
applicant is
is applying
applying for:
for:
The
Title: Mr
(Mr, Miss,
Ms or Mrs)
Mr
Endeavour Research
Fellowship
Application
ID: ERF_PDR_134977_2015
Gender:
Male
Female
(If
(If known)
Unspecified
Hiro
Hiro
First Name:DETAILS
2. REFEREE
DateofBirth: 03/02/1982
03/02/1982
Suzuki
Last Name: Suzuki
Title: Professor
Preferred Name:
Former Name:
Last Name: Yamada
81 213
213 865
865 5574
5574
Cell/Mobile: + 81
(Please
include country and area codes)
Organisation: Hitotsubashi
University
EX
AM
First Name: Tatsuke
81 213
213 854
854 3719
3719
Phone: + 81
(Please
include of
country
and area codes)
Position Held: Dean,
Department
Engineering
[email protected]
Phone: [email protected]
Email Address:
81 323 196 1347
Mobile: 81 323 186 5543
(Please include
include country and area codes)
(Please
Alternate [email protected]
[email protected]
Email Address:
Email: [email protected]
Postal
Postal Address
Address
EQUITY & DIVERSITY
Address Line
Line 1:
1: 2-1 Naka
Address
Are you an Australian Aboriginal or Torres Strait Islander? (Australian applicants only)
Address Line 2: Kunitachi
Yes
No
Choose not to give
City/Suburb: Tokyo
State/Province: Tokyo Prefecture
Do you identify as an indigenous or first nations person of your home country ? (International applicants only)
Postcode: 186-8601
County: Japan
Country:
Yes
No
Choose not to give
Relationship to applicant
Length of relationship
Are you from a non-English
speaking background?
Current supervisor
2
Yes
No
Years
Years
Language
Choose not to give
Japanese
Japanese
3
Months
3. APPLICANT
EVALUATION
Do
you have a disability?
evaluate the
the applicant
applicant
against the
the criteria
criteria below,
below, in
inChoose
terms of
of
your
experience.
Please
terms
your
experience.
Yes evaluate
No against
not
to give
Top 5%
5% == Excellent,
Excellent, Top
Top 10%
10% == Very
Very Good,
Good, etc.)
etc.)
(Example: Top
Residential Address
(where you are currently living)
Academic/professional achievement
Poor
Average
Address Line 1: 25-10-20
25-10-20 Higashiyama
Higashiyama
Leadership qualities
Address Line 2:
Personal integrity
Address Line 1:
City/Suburb: Sendai
Sendai City
City
Capacity to communicate and relate well to others
City/Suburb:
State/Province:
Postcode:
Country:
Miyagi
Prefecture
Miyagi
Prefecture
Resourcefulness
and initiative
�
�
�
�
State/Province:
Postcode:
Japan
Japan Adaptability to new situations
Country:
Potential for future contribution in field of study
Unable to
Postal Address ✔ (tick if same as residential)
Good
Very Good
Excellent
comment
Do not complete below if above box is ticked.
Address Line 2:
Emotional maturity
980-0856
980-0856
Type
�
�
�
�
8
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Endeavour Scholarships and Fellowships Application
2. CITIZENSHIP AND RESIDENCY
Country of Citizenship
Country of Permanent Residency
Japan
Japan
Japan
Japan
Do you hold dual citizenship with another country(ies)?
No
Yes
Canada
Canada
Country(ies)
In which country do you propose to undertake your Endeavour scholarship or fellowship?
Australia
Australia
3. PROPOSED PROGRAM
PL
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Please indicate the Endeavour scholarship or fellowship you are applying for:
4. Endeavour Executive Fellowship
1. Endeavour Postgraduate Scholarship (international)
Doctorate Degree (PhD)
Masters Degree by Coursework
Masters Degree by Research
Professional Development
2. Endeavour Vocational Education & Training Scholarship
(international)
Diploma
Advanced Diploma
Long-term study/research towards an Australian Masters
Long-term study/research towards an Australian PhD
EX
AM
Associate Degree
5. Endeavour Postgraduate Scholarship (Australian)
3. Endeavour Research Fellowship
6. Endeavour QEII Diamond Jubilee Scholarship
Short-term postdoctoral research
Long-term postdoctoral research
Short-term research towards a Masters Degree
Long-term research towards a doctoral degree
Short-term research towards a Doctorate Degree
Please specify your proposed field of study, research or professional development.
e.g. education, engineering, environment, health, information technology, management
Engineering
Engineering
Proposed host organisation:
University
University of
of Sydney
Sydney
Proposed Start Date: 01/02/2017
01/02/2017
Home organisation
Tohoku
Tohoku University
University
Proposed End Date: 01/06/2017
01/06/2017
Country of home organisation
Japan
Japan
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Endeavour Scholarships and Fellowships Application
3. PROPOSED PROGRAM (CONTINUED)
Pleasesummarise,inwordsthatcanbeunderstoodbyapersonoutsideyourfield,detailsofyourproposedprogram,whyyouchoseyour
proposed host organisation and what your proposed program is intended to achieve.
Alsoprovidedetails,includingproposeddatesandlocationsofanyproposedfieldworkand/orinternships (maximum 300 words).
4. EDUCATIONAL QUALIFICATIONS
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My
My proprosed
proprosed program
program will..........
will..........
Please provide details of your educational qualifications:
Pleaseattachaseparatelistifyouhavecompletedmorethanthreequalifications.
EX
AM
PhD
Qualification: PhD
Tohoku University
University
Institution: Tohoku
Japan
Country of enrolment: Japan
Commencement date:
Study Status:
02/04/2014
02/04/2014
Completed
Completion/Expected completion date
02/04/2018
02/04/2018
Undergoing
Qualification: Masters
Masters of
of Engineering
Engineering
Institution:
Simon Fraser
Simon
Fraser University
University
Country of enrolment:
Canada
Canada
Commencement date:
05/06/2010
05/06/2010
Study Status:
Completed
Completion/Expected completion date
07/06/2013
07/06/2013
Undergoing
5. EVIDENCE OF ENROLMENT OR CONFERMENT
For Endeavour Research Fellowship, Endeavour Postgraduate Scholarship (Australian), Endeavour QEII Scholarship and Endeavour
Research Fellowship for Indigenous Australians applicants only.
I am currently enrolled in a Masters degree and will undertake research while on my Endeavour program towards my Masters.
I am currently enrolled in a PhD degree and will undertake research while on my Endeavour program towards my PhD.
I am currently enrolled in a PhD degree and will complete my PhD before I commence my Endeavour program.
I have completed a PhD and will undertake postdoctoral research as my Endeavour program.
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Endeavour Scholarships and Fellowships Application
6. LANGUAGE REQUIREMENTS/PROFICIENCY
All applicants are required to provide evidence of language ability. Please see the relevant section of the Application Guidelines and submit
the required documentation with your application.
7. SCHOLARSHIPS, AWARDS, MEMBERSHIPS AND PUBLICATIONS
1. Have you previously completed an Endeavour scholarship or fellowship?
Yes
No
2. Do you currently hold or have you completed an Australian Government administered scholarship and/or fellowship?
Yes
No
Commencement date
Completion/Expected completion date
3. Have you completed any other scholarship or awards?
Yes
No
Scholarships/Awards
Institution
University Medalist
Medalist
University
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4. Please provide details of relevant scholarships and awards, professional memberships and publications.
Please attach a separate list if you have additional scholarships, memberships or publications.
Scholarships/Awards
Country
Year Awarded
Hitotsubashi University
University
Hitotsubashi
Japan
Japan
2009
2009
President's Scholarship
Scholarship
President's
Simon Fraser
Fraser University
University
Simon
Canada
Canada
2010
2010
Merit
Merit Scholarship
Scholarship
Hitotsubashi
Hitotsubashi University
University
Japan
Japan
2011
2011
Memberships
Membership
Engineers
Engineers Without
Without Boarders
Boarders
Membership type
Japan
Japan
Member
Member
Japan
Japan
Executive
Executive Member
Member
EX
AM
Hitotsubashi Engineers
Engineers Society
Society
Hitotsubashi
Country
Publications
Author(s):
Publication title:
Publisher/Journal title:
Language of Publication:
Author(s):
H.
H. Suzuki,
Suzuki,
A Guide
A
Guide to
to Modern
Modern Engineering
Engineering
Engineers
Engineers Monthly
Monthly
Japanese
Japanese
2010
Year of Publication: 2010
H. Suzuki,
Suzuki, B.
B. Ishida,
Ishida, H.
H. Johnstone
Johnstone
H.
Publication title: Advanced
Advanced Theories
Theories in
in Modern
Modern Engineering
Engineering
Publisher/Journal title:
Language of Publication:
Engineers
Engineers Digest
Digest
English
English
Year of Publication:
2014
2014
8. EMPLOYMENT HISTORY
Please provide details of relevant employment history beginning with your current or most recent employment.
Job Title
Employer Name
Country of Employment
Start month and year
End month and year
Senior Project
Senior
Project Manager
Manager
Ishida &
Ishida
& Associates
Associates Pty
Pty Ltd
Ltd
Japan
Japan
02/2014
02/2014
07/2016
07/2016
Project Manager
Project
Manager
Ishida
Ishida &
& Associates
Associates Pty
Pty Ltd
Ltd
Japan
Japan
03/2010
03/2010
01/2014
01/2014
Administrate Assistant
Assistant
Administrate
New Design
New
Design Engineering
Engineering
Canada
Canada
05/2008
05/2008
11/2009
11/2009
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Endeavour Scholarships and Fellowships Application
9. REFEREES
Please provide details of two referees. It is your responsibility to ensure that referee reports are received by the Endeavour Management
Team by the closing date.
Ms
Title: Ms
Rebecca
First name: Rebecca
Frost
Last name: Frost
Ishida &
& Associates
Associates Pty
Pty Ltd
Ltd
Organisation: Ishida
Chief Engineer
Engineer
Position: Chief
[email protected]
Email: [email protected]
81 323
323 122
122 3215
3215
Phone: + 81
(Please include country and area codes)
Prof
Title: Prof
Yamada
Last name: Yamada
Tatsuke
First name: Tatsuke
Department of
of Engineering
Engineering
Dean, Department
Position: Dean,
University
Hitotsubashi University
Organisation: Hitotsubashi
81 323
323 196
196 1347
1347
Phone: + 81
PL
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[email protected]
Email: [email protected]
(Please include country and area codes)
10. HOST NOMINATION
To be completed only by Endeavour Executive Fellowship, Endeavour Research Fellowship (including REF for Indigenous Australians)
and QEII applicants only.
Mr
Title: Mr
Michael
First name: Michael
The University
University of
of Sydney
Sydney
Organisation: The
[email protected]
Email: [email protected]
Smith
Last name: Smith
Senior Researcher
Researcher
Position: Senior
61 2
2 8435
8435 9946
9946
Phone (Business): + 61
EX
AM
(Please include country and area codes)
11. PROGRAM SUPPORTING STATEMENT
Please provide details of how your proposed program would further your academic and/or professional career (maximum 200 words).
My
My proposed
proposed program
program will
will allow
allow me
me to
to .....
.....
Please provide details of how your proposed program will benefit Australia and your potential to foster ongoing collaboration and
cooperation with your home and host countries (maximum 200 words).
My proposed
foster ongoing
ongoing collaboration
collaboration by
by .....
.....
My
proposed program
program will
will foster
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Endeavour Scholarships and Fellowships Application
12. PERSONAL STATEMENT
Please explain how receiving an Endeavour scholarship or fellowship would make a difference to your personal life (maximum 200 words).
13. SUPPORTING DOCUMENTS CHECKLIST
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II strongly
strongly believe
believe that
that .....
.....
EX
AM
Please refer to the Applicant Guidelines to ensure that your supporting documents meet the scholarship and fellowship requirements.
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Endeavour Scholarships and Fellowships Application
14.PRIVACY AND PUBLICITY CONSENTS AND AGREEMENT
Privacy Act 1988
The Department of Education and Training (‘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.
‘PersonalInformation’isdefinedbysection6ofthePrivacyActas: “information or an
opinion about an identified individual, or an individual who is reasonably identifiable
:(a) whether the information or opinion is true or not, and(b) whether the information or
opinion is recorded in a material form or not.”
The department collects Personal Information from applicants in order to assess their
applications and administer the Endeavour Scholarships and Fellowships. Applicants
are not required to provide Personal Information to the department but without collecting
Personal Information the department will not be able to process an application or
administer the Endeavour Scholarships and Fellowships for successful applicants.
The department will also collect Personal Information from successful applicants over
the duration of their Endeavour Scholarship and Fellowship, including their image in
photographs,filmfootage,images,andtheirwords,quotesorothercommentsmadeby
or attributed to them, in so far as it relates to their participation in, and experience of, the
Endeavour Scholarship and Fellowship.
• assessing applications
• administering the Endeavour Scholarships and Fellowships
Privacy and Publicity Consents and Agreement
By submitting an application:
• I consent to my Personal Information (including sensitive information) provided to,
and collected by, the department in relation to applications under the Endeavour
Scholarships and Fellowships being used for the Purposes and disclosed to the
recipients as described in the ‘Privacy Notice’
• I understand that the department will not provide individual feedback if my application
is unsuccessful. I will be provided with generic reasons why many of the Endeavour
Scholarship Fellowship applications do not receive an offer via the Endeavour website
at the conclusion of the round
• I understand that if my Personal Information is disclosed and/or published on the
internet as described in this ‘Privacy Notice’:
• my Personal Information will be available to the public on the world wide web and may
be viewed by members of the public in Australia and/or individuals or parties located
overseas;
PL
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Personal Information (including sensitive information) provided to the department by
applicants (including Personal Information collected by the department from successful
applicants over the duration of the Endeavour Scholarships and Fellowships) will only
be used by the department for the following purposes (‘the Purposes’):
Applicants are not required to provide their consent to the collection and publication of
Materials as described in this Publicity Notice and may withdraw their consent at any
time, prior to the publication of the Material, by contacting the department in writing at
[email protected].
• promoting the Endeavour Scholarship and Fellowships, including in promotional
material, photographs, audio visual, media releases, information and publications in
hardcopy and/or on the internet and
• congratulating and/or inviting successful recipients and alumni to functions and events
held in Australia and overseas.
Please note, any Personal Information that is used in promotional materials and/or
published on the internet will be available to the public (including on the world-wide web)
and may be viewed by members of the public in Australia and/or individuals or parties
located overseas. The department will have no control over who views the Personal
Information published on the internet or how a member of the public may use the
Personal Information.
- Australian Privacy Principle 8.1 will not apply if the Personal Information is viewed or
used by an individual or parties located overseas; and
- an individual or parties located overseas will not be accountable under the Privacy
Act and as a result I will not be able to seek redress under the Privacy Act for any
privacy breaches committed by the individual or parties located overseas.
• I agree that the Material may be used by the department for the purpose or promoting
the Endeavour Scholarship and Fellowships at any time in the future, even if
information about me in the Material (such as my employment status) has ceased to
be true
• I understand and agree that I will not receive, and am not entitled to receive, any
payment for the use, disclosure or publication of the Material
• I grant, to the extent (if any) that I own intellectual property rights in the Material or any
part of the Material, a perpetual, world-wide and royalty-free licence to the department
and its Agents to copy and disseminate the Materials in accordance with this Publicity
Notice
EX
AM
The department may disclose personal information in relation to applications under the
Endeavour Scholarships and Fellowships for the Purposes listed above to the following
recipients:
- the department will have no control over who views my Personal Information
published on the internet or how a member of the public may use the Personal
Information;
• 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
• the department’s contractors and agents
• Australian universities and participating Australian organisations and
• Other individuals or parties located overseas who may access Personal Information
published in promotional materials and/or on the internet.
Applicants are not required to provide their consent to the collection, use and disclosure
of Personal Information as described in this Privacy Notice and may withdraw their
consent in writing by contacting the department at [email protected].
au. However, this will mean that the department may not be able to consider their
application and/or administer and promote the Endeavour Scholarship and Fellowships.
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].
• I agree that the department:
- is not obliged to, and has not represented to me that they will, publish the Material
- does not have to identify me as author of any of the Material which they do publish or
otherwise communicate and
-mayedittheMaterialpriortopublicationasitseesfitwithoutfirstcheckingwithme.
By submitting an application, I understand and agree that if I am successful and accept
an Endeavour Scholarship or Fellowship:
• I will provide the department, through Scope Global, regular reports on my progress
andafinalreportatthecompletionofmyprogram
•IwillactinamannerbefittingarecipientofanEndeavourscholarshiporfellowship
• I will use the funds for the purposes granted
• I will acknowledge the assistance given by the Australian Government in any written
reports, publications or publicity
•Iwillundergoapolicecheckbeforemyofferisconfirmed(Australiansonly)
• I consent to the collection, use and disclosure of my Personal Information, in the
manner described in the ‘Privacy Notice’ for the duration of my Endeavour Scholarship
and Fellowship
Publicity Notice
• I agree and consent to the publication of Material as described in the ‘Publicity Notice’
For the purpose of promoting the Endeavour Scholarships and Fellowship Program
(‘Program’),thedepartmentmaycollectandpublishimages,photos,filmfootage,
words, quotes or other comments made by or attributed to successful applicants,
and any other Personal Information about successful applicants (including sensitive
information), collected in connection with the Program (together, the ‘Material’). The
department may collect the Material during the term of the successful applicant’s
Endeavour Scholarship and Fellowship, and use and publish the Material for the
purpose of promoting the Program, at any time.
Terms and Conditions
The department may disclose the Material to any person or organisation, including
without limitation by publishing it:
• as, or as part of, any book, newspaper advertisement or article
• television advertisement or program
• I have the right to withdraw my consent to the publication of the Material on the
internet at any time prior to the publication of the Material, by contacting endeavour@
education.gov.au in writing.
• I declare that I have read and understood the Privacy Notice above
• I declare that I have read and understood the Publicity Notice above
• I declare that I have read and understood the Privacy and Publicity Consent and
Agreement Statement above
• I declare that the contents of my application are true, and
• I acknowledge that giving false or misleading information is a serious offence under
the Criminal Code (Commonwealth).
• radio advertisement or program and
• on the internet and in any other media.
Signature
Hiro Suzuki
Hiro
Suzuki
Date (dd/mm/yyyy)
09/06/2016
09/06/2016
Print Form
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).
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