1.

PERSONAL DETAILS
Title:
Gender:

Male

Female
Date of Birth:
First Name: Family Name:
Preferred Name: Former Name:
Phone:
+
Cell/Mobile:
+
(Please include country and area codes) (Please include country and area codes)
Email Address:
Alternate
Email Address:
EQUITY & DIVERSITY
Indigenous (Australians only)

Aboriginal

Torres Strait Islander

Choose not to give
Non English Speaking Background

Yes

No

Choose not to give

Language
Disability

Yes

No

Choose not to give

Type
Residential Address
(where you are currently living)

Postal Address

(tick if same as residential)
Do not complete below if above box is ticked.
Address Line 1: Address Line 1:
Address Line 2: Address Line 2:
City/Suburb: City/Suburb:
State/Province: State/Province:
Postcode: Postcode:
Country: Country:
Endeavour Scholarships &
Fellowships Application
Submitting Your Application

Please ensure that you have read the Endeavour Scholarships and Fellowships applicant guidelines available on the website
before completing this form. Return your application forms and the required supporting documentation to us at:
Endeavour Management Team
Australian Government Department of Education
International Group, GPO Box 9880
Canberra ACT 2601, AUSTRALIA

Incomplete or late applications will not be accepted
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Mr 01/01/1990
John Suzuki
81 213 854 3719 81 213 865 5574
John.Suzuki@hotmail.com
John.Suzuki@gmail.com

Japanese

25-10-20 Higashiyama
Sendai
Miyagi
980-0856
Japan
Main Round closing date: 31 July 2009
Second Round closing date: 31 January 2010
2010
Endeavour Scholarships and Fellowships Application
Prime
2. CITIZENSHIP AND RESIDENCY
Country of Citizenship Country of Permanent Residency
Do you hold dual citizenship with another country(ies)?
No Yes
Country(ies)
In which country do you propose to undertake your Endeavour Scholarship or Fellowship?:
Please note, applicants must not choose a host country or part of a country that has been assessed by the Department of Foreign Affairs and
Trade (DFAT) as an area not to travel (Level 4). Further information is available at www.dfat.gov.au.
3. PROPOSED PROGRAMME
Please indicate the Endeavour Scholarship or Fellowship you are applying for and the type of activity you would like to undertake:
1. Endeavour Postgraduate Scholarship (non-Australian) 4. Endeavour Executive Fellowship
Doctorate Degree (PhD) Professional Development
Masters Degree by Coursework
Masters Degree by Research
2. Endeavour Vocational Education & Training (VET) Scholarship
(non-Australian)
5. Endeavour Postgraduate Scholarship (Australian)
Diploma Long-term study/research towards an Australian Masters
Advanced Diploma
Long-term study/research towards an Australian PhD
Associate Degree
3. Endeavour Research Fellowship (including Indigenous Fellowships) 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 feld of study, research or professional development:
e.g. education, engineering, environment, health, information technology, management
Proposed host institution/organisation: (If more than one, please list in order of preference)
1.
2.
3.
Proposed Start Date:

Proposed End Date:
Home institution/organisation Home institution/organisation country
Applicants applying for an Endeavour Postgraduate Scholarship (non-Australian) or Endeavour VET Scholarship require an admission letter (letter
of offer) from an Australian university/institution.
Applicants applying for an Endeavour Research Fellowship (including QE II and Indigenous Fellowships), Endeavour Executive Fellowship or
Endeavour Postgraduate Scholarship (Australian) require an Endeavour Scholarships and Fellowships nomination form to be completed by their
proposed host.
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Japan Japan
Canada
Australia
Engineering
Monash University
The University of Sydney
The Australian National University
01/02/2015 05/07/2015
Tohoku University Japan
Main Round closing date: 31 July 2009
Second Round closing date: 31 January 2010
2010
Endeavour Scholarships and Fellowships Application
Prime
4. EDUCATIONAL QUALIFICATIONS
Please provide details of your educational qualifcations:
Please attach a separate list if you have completed more than three qualifcations.
Qualifcation:
Institution:
Country of enrolment:
Start and end years:
Study Status:
Completed On-going
Qualifcation:
Institution:
Country of enrolment:
Start and end years:
Study Status:
Completed On-going
Qualifcation:
Institution:
Country of enrolment:
Start and end years:
Study Status:
Completed On-going
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3. PROPOSED PROGRAMME (CONTINUED)
Summary of Programme: Please summarise, in words that can be understood by a person outside your feld, what your proposed
programme is intended to achieve, why you would like to undertake the proposed programme and how it is related to your prior experience
and/or future career goals. Please also provide details, including proposed dates and locations, of any proposed feldwork and/or internships
(maximum 300 words).
My Proposed Programme is .............
PhD
Tohoku University
Japan
2012 - 2016
Masters of Engineering
Hitotsubashi University
Japan
2009 - 2011
Bachelor of Engineering
Simon Fraser University
Canada
2005-2009
Main Round closing date: 31 July 2009
Second Round closing date: 31 January 2010
2010
Endeavour Scholarships and Fellowships Application
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5. LANGUAGE REQUIREMENTS/PROFICIENCY
Endeavour Postgraduate Scholarship (non-Australian) and Vocational Educational Training Scholarship applicants must provide (a) or (b):
(a) IELTS/TOEFL A certifed copy of an offcial, valid IELTS or TOEFL test result. Results are valid for two years. Tests that are provided with
a test date that is before 30 June 2012 will not be accepted and the application will be marked ineligible. Test scores will need to meet the
minimum requirements (see table below);
Test Type Requirements for all categories
IELTS Academic Test result ONLY Overall score of 6.5 with no individual band less than 6.0
TOEFL Paper Based Test (PBT) Score of 580 including a TWE (Test of Written English) score of 4.5
TOEFL Computer Based Test (CBT) Score of 230 including an Essay Rating score of 4.5
TOEFL Internet Based Test (IBT) Overall score of 90 with a minimum score of 22 in the writing section and no less than 20 in the other sections
(b) A certifed copy of an academic transcript as proof of completion of one full year of University level study minimum conducted in English in
(not by correspondence) one of the following listed countries*
American Samoa, Australia, Botswana, Canada, Fiji, Ghana, Guyana, Ireland, Jamaica, Kenya, Lesotho, Liberia, New Zealand, Nigeria,
Papua New Guinea, Singapore, Solomon Islands, South Africa, Tonga, Trinidad and Tobago, United Kingdom (including Northern Ireland),
United States of America, Zambia or Zimbabwe.
* This list is determined by the Universities Admissions Centre (UAC) and is part of a collective agreement with Australian Universities.
All Endeavour Research Fellowship, Endeavour Executive Fellowship and Endeavour Queen Elizabeth Diamond Jubilee Scholarship
applicants must provide:
At least one completed nomination from their host organisation to undertake their programme in 2015
Your host organisation must confrm via the nomination form that your language ability is suitable for your proposed programme. If they do not
confrm this, you will be ineligible and your application will not be considered further.
6. SCHOLARSHIPS, AWARDS, MEMBERSHIPS AND PUBLICATIONS
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
Scholarships/Awards Institution Country Year Awarded
Memberships
Membership Country Membership type
Publications
Author(s):
Publication title:
Publisher/Journal title:
Language of Publication:
Year of Publication:
Author(s):
Publication title:
Publisher/Journal title:
Language of Publication:
Year of Publication:
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University Medalist Simon Fraser University Canada 2009
President's Scholarship Hitotsubashi University Japan 2010
Merit Scholarship Hitotsubashi University Japan 2011
Engineers without Boarders Japan Member
Hitotsubashi Engineers Society Japan Executive Member
J. Suzuki
A guide to modern engineering
Engineers Monthly
Japanese
2010
J. Suzuki, B. Ishida, H. Johnstone
Advanced theories in modern engineering
Engineers Digest
English
2014
Endeavour Scholarships and Fellowships Application
Prime
7. 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
8. REFEREES
Please provide details of two referees. It is your responsibility to ensure that referee reports are received by the Department by the closing
date.
Title: First name:
Family name:
Organisation: Position:
Email: Phone: +
(Please include country and area codes)
Title: First name:
Family name:
Organisation: Position:
Email: Phone: +
(Please include country and area codes)
9. HOST NOMINATION
To be completed by Endeavour Executive Fellowship and Endeavour Research Fellowship (including QE II and Indigenous Fellowship)
applicants only
Title: First name:
Family name:
Organisation: Position:
Email: Phone (Business): +
(Please include country and area codes)
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Senior Project Manager Ishida & Associates Pty Ltd Japan 01/02/2014 Current
Project Manager Ishida & Associates Pty Ltd Japan 03/03/2010 30/01/2014
Administrate Assistant New Design Engineering Canada 03/05/2008 30/11/2009
Ms Rebecca Frost
Ishida & Associates Pty Ltd Chief Engineer
Rebecca.Frost@ia.co.jp 81 323 122 3215
Prof Tatsuke Yamada
Hitotsubashi University Dean, Department of Engineering
T.Yamada@hitotsubashi.ac.jp 81 323 196 1347
Mr David Meyer
Monash University Researcher, Faculty of Engineering
D.Meyer@Monash.edu.au 61 3 8946 4453
Endeavour Scholarships and Fellowships Application
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10. PROGRAMME SUPPORTING STATEMENT
Please provide details of your proposed programme including how it will contribute to the achievement of your personal goals and
further your academic and/or professional career (maximum 500 words).
If additional space is required, please attach a separate document.
Please provide details of how your proposed programme will beneft Australia and your potential to foster ongoing collaboration and
cooperation with your home and host country/region (maximum 200 words).
Please provide details and evidence of your service to the community, unpaid service within your feld of expertise, or unpaid
community service in outside capacities (maximum 200 words).
11. PERSONAL STATEMENT
Please provide a personal statement supporting your application (maximum 200 words).
My proposed programme will allow me to.........
My proposed programme will foster ongoing collaboration by .........
I have provided service to my community by.........
I strongly believe that.......
Endeavour Scholarships and Fellowships Application
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12. SUPPORTING DOCUMENTS CHECKLIST
Please refer to the Applicant Guidelines to ensure that your supporting documents meet the Scholarship and Fellowship requirements.
Please note that your supporting documents must be in English (approved translations accepted) and where stated must be certifed/
attested by an approved authority.
To be eligible, applicants must:
Provide the supporting documentation specifed for the category for which they are applying (see applicant guidelines for further
information)
Provide an English translation if the original document is not in English
Applications that do not contain the necessary documentation will be deemed incomplete and therefore ineligible and will not be
considered further
Applicants must provide certifed (attested) copies of:
Citizenship
Permanent residency (if applicable)
Academic transcripts
Language profciency (IELTS or TOEFL results)
To certify a document as a true copy, applicants should provide the original and a copy of the document to a formallyrecognised
authority. This could include but is not limited to; Justice of the Peace, Commissioner of Oaths, Public Notary, Lawyer, Doctor, Civil
Servant, Teacher, work supervisor, university Dean or course convener. The cost of any fees charged bynotaries for certifcation of
documents is the responsibility of the applicant.
The certifer should:
1. Sight the original against the copy of the document
2. Write or use a stamp (if available), I certify that the copy is a true copy of the original document
3. Sign under the statement and provide details of their occupation.
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Academic transcripts

Evidence of community service

Referee reports x 2

Evidence of language profciency

Evidence of Admission to an Australian University

Evidence of Nomination and Language
Suitability from Host

Employment record

Evidence of enrolment / PhD conferment

Evidence for Indigenous Australians
*
*Australian applicants applying for an Endeavour Research Fellowship for Indigenous Australians only
Notice:
The information contained in this email message and any attached fles may be confdential information, and may also be the subject of legal
professional privilege. If you are not the intended recipient any use, disclosure or copying of this email is unauthorised. If you received this email in
error, please notify the sender by contacting the departments switchboard on 13 33 97 during business hours (8am - 5pm Local time) and delete all
copies of this transmission together with any attachments.
Endeavour Scholarships and Fellowships Application
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13. TERMS AND CONDITIONS
Privacy Notice
Privacy Act 1988
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 is defned by section 6 of the Privacy Act as:
information or an opinion about an identifed individual, or an individual
who is reasonably identifable:
(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.
Without collecting your personal information the Department of
Education (the Department) will not be able to process your application.
Your 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
administering the Endeavour Scholarships and Fellowships
promoting the Endeavour Scholarship and Fellowships, including in
promotional material, information and publications in hardcopy and/or
on the internet, and
congratulating and/or inviting successful recipients to functions and
events held in Australia and overseas.
The Department may disclose personal information in relation to
applications under the Endeavour Scholarships and Fellowships to the
following recipients:
Australian Government Departments and agencies, including
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 Departments contractors, including Austraining International and
Cheung Kong Holdings Ltd
Australian Universities, and
participating Australian Institutions.
for the same purposes listed above.
For information on the Departments privacy policy, including
information on how the Department handles personal information,
how you can access or correct personal information, or how to make a
complaint, go to http://education.gov.au/privacy or you may request a
copy of the privacy policy from privacy@deewr.gov.au.
Authorisation and Agreement
By submitting this application:
I authorise for my personal information (including sensitive
information) provided to the Department in relation to applications
under the Endeavour Scholarships and Fellowships be used for
the purposes and disclosed to the recipients listed as per the
Privacy Notice, and
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 and
Fellowship applications do not receive an offer via the Endeavour
website at the conclusion of the round.
I agree that if I am successful receiving an offer and accept an
Endeavour Scholarship or Fellowship:
I will provide the Department, through Austraining International,
regular reports on my progress and a fnal report at the
completion of my programme,
I will act in a manner beftting a recipient of an Endeavour
Scholarship or Fellowship,
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, and
I will undergo a police check before my offer is confrmed
(Australians only).
Terms and Conditions
I declare that I have read and understood the Privacy Notice above.
I declare that I have read and understood the Authorisation 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)
Signature Date (dd/mm/yyyy)
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* 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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John Suzuji
05/05/2015