2015

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 1. PERSONAL DETAILS Title: Mr

Gender:

Male

Female

First Name: John

Date of Birth: 01/01/1990 Family Name: Suzuki

Preferred Name:

Former Name:

Phone: + 81 213 854 3719

(Please include country and area codes)

Cell/Mobile: + 81 213 865 5574

(Please include country and area codes)

Email Address: [email protected] Alternate [email protected] 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

No

Choose not to give

Language Japanese

Disability

✔

Yes

Postal Address

Residential Address (where you are currently living) Address Line 1:

Address Line 2:

Address Line 2:

City/Suburb: Sendai

City/Suburb:

State/Province: Miyagi

State/Province:

Country: Japan

(tick if same as residential)

Do not complete below if above box is ticked.

Address Line 1: 25-10-20 Higashiyama

Postcode: 980-0856

Type

Postcode: Country:

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Main Round closing date: 31 July 2009 Endeavour Scholarships and Fellowships Application Second Round closing date: 31 January 2010

2. CITIZENSHIP AND RESIDENCY

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Country of Citizenship

Country of Permanent Residency

Japan

Japan

Do you hold dual citizenship with another country(ies)? No

Yes

Country(ies)

Canada

In which country do you propose to undertake your Endeavour Scholarship or Fellowship?:

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Australia

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 field of study, research or professional development:

e.g. education, engineering, environment, health, information technology, management

Engineering Proposed host institution/organisation: (If more than one, please list in order of preference) 1. Monash University 2. The University of Sydney 3. The Australian National University Proposed Start Date:

01/02/2015

Proposed End Date: 05/07/2015

Home institution/organisation

Home institution/organisation country

Tohoku University

Japan

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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Main Round closing date: 31 July 2009 Endeavour Scholarships and Fellowships Application Second Round closing date: 31 January 2010

3. PROPOSED PROGRAMME (CONTINUED)

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Summary of Programme: Please summarise, in words that can be understood by a person outside your field, 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 fieldwork and/or internships (maximum 300 words).

My Proposed Programme is .............

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4. EDUCATIONAL QUALIFICATIONS Please provide details of your educational qualifications: Please attach a separate list if you have completed more than three qualifications. Qualification: PhD Institution: Tohoku University Country of enrolment: Japan Start and end years: 2012 - 2016 Study Status:

Completed

On-going

Qualification: Masters of Engineering Institution: Hitotsubashi University Country of enrolment: Japan Start and end years: 2009 - 2011 Study Status:

Completed

On-going

Qualification: Bachelor of Engineering Institution: Simon Fraser University Country of enrolment: Canada Start and end years: 2005-2009 Study Status:

Completed

On-going

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Main Round closing date: 31 July 2009 Endeavour Scholarships and Fellowships Application Second Round closing date: 31 January 2010

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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 certified copy of an official, 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

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TOEFL – Computer Based Test (CBT) Score of 230 including an Essay Rating score of 4.5 TOEFL – Internet Based Test (IBT)

(b)

Overall score of 90 with a minimum score of 22 in the writing section and no less than 20 in the other sections

A certified 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 confirm via the nomination form that your language ability is suitable for your proposed programme. If they do not confirm 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

University Medalist

Simon Fraser University

Canada

2009

President's Scholarship

Hitotsubashi University

Japan

2010

Merit Scholarship

Hitotsubashi University

Japan

2011

Memberships Membership

Country

Membership type

Engineers without Boarders

Japan

Member

Hitotsubashi Engineers Society

Japan

Executive Member

Publications Author(s): J. Suzuki Publication title: A guide to modern engineering Publisher/Journal title: Engineers Monthly Language of Publication: Japanese Year of Publication: 2010 Author(s): J. Suzuki, B. Ishida, H. Johnstone Publication title: Advanced theories in modern engineering Publisher/Journal title: Engineers Digest Language of Publication: English Year of Publication: 2014

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2015

Endeavour Scholarships and Fellowships Application 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

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

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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: Ms

First name: Rebecca

Organisation: Ishida & Associates Pty Ltd Email: [email protected] Title: Prof

First name: Tatsuke

Organisation: Hitotsubashi University Email: [email protected]

Family name: Frost Position: Chief Engineer Phone: + 81 323 122 3215

(Please include country and area codes)

Family name: Yamada Position: Dean, Department of Engineering Phone: + 81 323 196 1347

(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: Mr

First name: David

Organisation: Monash University Email: [email protected]

Family name: Meyer Position: Researcher, Faculty of Engineering Phone (Business): + 61

3 8946 4453

(Please include country and area codes)

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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.

My proposed programme will allow me to.........

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Please provide details of how your proposed programme will benefit Australia and your potential to foster ongoing collaboration and cooperation with your home and host country/region (maximum 200 words).

My proposed programme will foster ongoing collaboration by .........

Please provide details and evidence of your service to the community, unpaid service within your field of expertise, or unpaid community service in outside capacities (maximum 200 words).

I have provided service to my community by.........

11. PERSONAL STATEMENT Please provide a personal statement supporting your application (maximum 200 words).

I strongly believe that.......

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2015

Endeavour Scholarships and Fellowships Application 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 certified/ attested by an approved authority. To be eligible, applicants must: • Provide the supporting documentation specified 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 certified (attested) copies of:

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• Citizenship • Permanent residency (if applicable) • Academic transcripts • Language proficiency (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 certification of documents is the responsibility of the applicant. The certifier 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.

Evidence of community service Referee reports x 2

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Evidence of language proficiency Evidence of Admission to an Australian University Evidence of Nomination and Language Suitability from Host Employment record

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Postgraduate

Academic transcripts

Research Fellowship (including QEII & Indigenous*)

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Executive Fellowship

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Research Fellowship

Citizenship / permanent residency

Australians

Executive Fellowship

VET

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Required Documents

Postgraduate

Certified copy required

Non-Australians

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Evidence of enrolment / PhD conferment Evidence for Indigenous Australians

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Notice: The information contained in this email message and any attached files may be confidential 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 department’s switchboard on 13 33 97 during business hours (8am - 5pm Local time) and delete all copies of this transmission together with any attachments.

*Australian applicants applying for an Endeavour Research Fellowship for Indigenous Australians only

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13. TERMS AND CONDITIONS Privacy Notice

Authorisation and Agreement

By submitting this application:

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 defined by section 6 of the Privacy Act as: “information or an opinion about an identified individual, or an individual who is reasonably identifiable:

• 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.

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(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 Department’s contractors, including Austraining International and Cheung Kong Holdings Ltd • Australian Universities, and • participating Australian Institutions.

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 final report at the completion of my programme, • I will act in a manner befitting 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 confirmed (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)

for the same purposes listed above. For information on the Department’s 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 [email protected].

Signature

Date (dd/mm/yyyy)

John Suzuji

05/05/2015

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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). 8 of 8