APPLICATION FORM

PHOTOGRAPH

        SHORT TERM PhD EXCHANGE
AUSTRALIA – BRAZIL
4 APRIL – 27 May 2016
        
Applications close: Monday 30 November 2015

PART A: PERSONAL DETAILS

Family name:

	

Other name(s):

		         Mr    Mrs   Miss   Ms     Dr				Male Female

Title:								Sex:

Place of birth:						Date of birth:

Nationality:
				
Correspondence Address and Phone Numbers (Please include mobile number):	

Email:			

Fluency in English:
	Professional Standard	Functional	Limited	Nil
Reading	☐	☐	☐	☐
Writing	☐	☐	☐	☐
Speaking	☐	☐	☐	☐
Listening	☐	☐	☐	☐

PART B: RESPONSE TO SELECTION CRITERIA

Please address each of the selection criteria including your skills and work/academic experience and include key examples demonstrating your ability against each selection criterion. Responses to each selection criteria must be in English.
  
1.	

Well-defined research programme, explaining the methodology and proposed steps for practical implementation (maximum 1,000 words).

2.	Record of high-level academic achievement and/or relevant work experience in the applicant’s chosen field of study (maximum 500 words).

3.	Statement on how the international research opportunity would further the applicant’s academic and/or professional career (maximum 500 words).

PART C: ACADEMIC BACKGROUND

Please list all relevant academic qualifications gained since completing your secondary education, stating the institutions attended, including the names of the courses and when they started and finished.  

Please indicate with an asterisk (*) those courses where the language of instruction or supervision was entirely or mostly English. 

Qualification
(including class or level)	Institution	Subject	  From	   To	

					

PART D: PROFESSIONAL BACKGROUND

Are you currently working? If so, please provide details of your employer, your position and your main duties.

Please list all relevant positions held since completing your tertiary education and outline your responsibilities. 

Please indicate with an asterisk (*) those positions where the main working language was English.
	
Position	Organisation/Institution	Responsibilities	   From	   To	

					

PART E: REFEREE CONTACT DETAILS (IN BRAZIL)

Please provide contact details and attach the report of a referee, who should be your PhD supervisor. 

REFEREE DETAILS

Title and name:
Position:
Work address
and telephone:

Email:

How long have you known this referee?

	

PART F: HOST CONTACT DETAILS (IN AUSTRALIA)

Please provide details and attach the nomination letter of your host at an Australian institution. 

HOST DETAILS

Title and name:

Position:

Institution:

                                                   	          Email:

 		                      Work address
 			                     and telephone:

	

                  

		

           Signed:							                            Date: 

* 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).

  ATTACHMENT A

REFEREE REPORT

• This attachment (pages 9 to 11) must be filled out by the referee in Brazil.
• The selection process for the Short Term PhD Exchange is merit-based and referee reports do not guarantee an offer.
• Referees may be contacted by the selection panel during the selection process.

APPLICANT DETAILS

Full name:
Research area:
Research title:

	

REFEREE DETAILS

Title and name:

Position:

Institution:

                                                   	          Email:

   			          Work address
 				         and telephone:

	

                  

1

APPLICANT SUITABILITY
Expand on your evaluation and provide reasons why, in your opinion, the applicant should be considered for the Short Term PhD Exchange. Include in your comments:

• The applicant’s suitability to undertake the proposed programme at the nominated organisation
(maximum 500 words).

I believe (applicant’s name) should be considered for the Short Term PhD Exchange because.....

• How the applicant’s participation in the programme can benefit the current research and what are the expected outcomes (maximum 500 words).

The research conducted by (applicant’s name) aims to…..

		

           Signed:							                            Date: 

* 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).
  ATTACHMENT B

NOMINATION FORM

• Nominations are to be made by the applicant’s host organisation in Australia. 
• This attachment (pages 12 and 13) must be filled out by the applicant’s proposed supervisor, who must hold a senior position within the host organisation.
• The host organisation should be aware of and agree with the programme period: 4 April - 27 May 2016.

APPLICANT DETAILS

Full name:
Research area:
Research title:

	

HOST DETAILS

Title and name:

Position:

Institution:

                                                   	          Email:

   			 Institution address:

 				              Telephone:

	

                  

1
Is the applicant’s language ability suitable to undertake the proposed programme 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.

PROPOSED PROGRAMME
Please provide a brief summary of the proposed programme (maximum 500 words).

The applicants proposed programme will.......

How will the proposed programme build or improve the linkages between the home and host organisations? (maximum 500 words)

The applicants proposed programme will.......

Why has the organisation chosen to nominate this applicant and what benefits will be gained from the proposed programme? (maximum 500 words)

The organisation has decided to nominate this applicant because of.........

3. PROPOSED PROGRAMME (continued) 

		

           Signed:							                            Date: 

* 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).