2017
2016
Endeavour Referee Report
The selection process
for theApplication
Endeavour Scholarships and Fellowships are merit-based and referee reports do not guarantee
Submitting
Your
an 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. APPLICANTCanberra
DETAILS
ACT 2601, AUSTRALIA
Incomplete or late applications will not be accepted
Title:
Last Name:
PL
First Name:
1. PERSONAL DETAILS
The Endeavour category the applicant is applying for:
Title:
Application
ID:
Gender:
(If known)
Mr
Male
(Mr, Miss, Ms or Mrs)
Female
Unspecified
Hiro
2. REFEREE
First Name:
DETAILS
Title:
Preferred Name:
Last Name: Suzuki
Former Name:
First Name:
81 213 854 3719
Phone: +
(Please include country and area codes)
Position Held:
Last Name:
Cell/Mobile: +
Organisation:
AM
Date of Birth: 03/02/1982
Phone: [Link]@[Link]
+
Email Address:
Alternate
Email Address:
Email:
81 213 865 5574
(Please include country and area codes)
Mobile:
(Please include country and area codes)
[Link]@[Link]
EX
Postal Address
EQUITY & DIVERSITY
Address Line 1:
Are you an Australian Aboriginal or Torres Strait Islander? (Australian applicants only)
Address Line 2:
Yes
Choose not to give
No
City/Suburb:
State/Province:
Do you identify as an indigenous or first nations person of your home country ? (International applicants only)
Postcode:
Country:
Yes
Choose not to give
No
Relationship to applicant
Length of relationship
Are you from a non-English speaking background?
Yes
No
Choose not to give
Years
Language
Japanese
Months
3. APPLICANT
EVALUATION
Do
you have a disability?
Please
evaluate the applicant
terms ofnot
your
experience.
Yes
to give
No against the criteria below, in Choose
(Example: Top 5% = Excellent, Top 10% = Very Good, etc.)
Type
Unable to
Residential Address Postal Address (tick if same as residential)
Poor
Average
Good
Very
Good
Excellent
comment
(where you are currently living)
Do not complete below if above box is ticked.
Academic/professional achievement
Address Line 1:
Address Line 1:
25-10-20 Higashiyama
Leadership qualities
Address Line 2:
Address Line 2:
Personal integrity
City/Suburb:
City/Suburb:
Sendai City
Capacity to communicate and relate well to others
State/Province:
State/Province:
MiyagiResourcefulness
Prefecture and initiative
Postcode:
980-0856
Emotional maturity
Postcode:
Country:
JapanAdaptability to new situations
Country:
Potential for future contribution in field of study
8
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2. CITIZENSHIP AND RESIDENCY
Country of Citizenship
Country of Permanent Residency
Japan
Japan
Do you hold dual citizenship with another country(ies)?
Yes
No
Country(ies)
Canada
In which country do you propose to undertake your Endeavour scholarship or fellowship?
Australia
Please indicate the Endeavour scholarship or fellowship you are applying for:
1. Endeavour Postgraduate Scholarship (international) 4. Endeavour Executive Fellowship
Masters Degree by Coursework
Masters Degree by Research
Professional Development
PL
Doctorate Degree (PhD)
3. PROPOSED PROGRAMME
2. Endeavour Vocational Education & Training Scholarship
5. Endeavour Postgraduate Scholarship (Australian)
(international)
Diploma
Long-term study/research towards an Australian Masters
Long-term study/research towards an Australian PhD
Advanced Diploma
AM
Associate Degree
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
EX
Engineering
Proposed host organisation:
University of Sydney
Proposed Start Date:
01/02/2017
Home organisation
Tohoku University
Proposed End Date: 01/06/2017
Country of home organisation
Japan
Endeavour Postgraduate Scholarship (international) and Endeavour VET Scholarship applicants require one admission letter from an
Australian university.
Endeavour Research Fellowship (including QE II and Indigenous), Endeavour Executive Fellowship and Endeavour Postgraduate Scholarship
(Australian) applicants require a nomination form to be completed by their proposed host. Applicants can list up to three hosts.
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3. PROPOSED PROGRAMME (CONTINUED)
Please summarise, in words that can be understood by a person outside your field, details of your proposed programme, why you chose your
proposed host organisation and what your proposed programme is intended to achieve.
Also provide details, including proposed dates and locations of any proposed fieldwork and/or internships (maximum 300 words).
4. EDUCATIONAL QUALIFICATIONS
PL
My proprosed programme will..........
Please provide details of your educational qualifications:
Please attach a separate list if you have completed more than three qualifications.
Qualification: PhD
AM
Institution: Tohoku University
Country of enrolment: Japan
Commencement date: 02/04/2014
Study Status:
Completed
Completion/Expected completion date* 02/04/2018
Undergoing
Qualification: Masters of Engineering
Institution: Simon Fraser University
Country of enrolment: Canada
EX
Commencement date: 05/06/2010
Study Status:
Completed
Completion/Expected completion date* 07/06/2013
Undergoing
*If an applicant has not completed an undergraduate degree but will complete by 31 December 2016, they must provide a letter from their
university to state when completion is expected. A condition will be placed on their application and a final transcript will be required if they are
successful in receiving a scholarship offer.
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 programme towards my Masters.
I am currently enrolled in a PhD degree and will undertake research while on my Endeavour programme towards my PhD.
I am currently enrolled in a PhD degree and will complete my PhD before I commence my Endeavour programme.
I have completed a PhD and will undertake postdoctoral research as my Endeavour programme.
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2017
Endeavour Scholarships and Fellowships Application
6. LANGUAGE REQUIREMENTS/PROFICIENCY
Endeavour Postgraduate Scholarship (International) and Vocational Educational Training Scholarship applicants must provide either (a) or (b):
(a) ELTS/TOEFL/CAE/PTE. A certified copy of an official, valid IELTS, TOEFL, CAE or PTE test result. Results are valid for two years.
Tests that are provided with a test date that is before 30 June 2014 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
Overall score of 6.5 with no individual band less than 6.0
TOEFL Paper Based Test (PBT)
Score of 580 including a Test of Written English (TWE) score of 4.5
TOEFL Internet Based Test (IBT)
Overall score of 79 with a minimum score of 21 in the writing section and no less than 19 in the other sections
CAE Cambridge English Advanced
ONLY Overall score of 176 with no individual band less than 169
PTE Academic Test result ONLY
Overall score of 58 with no individual band less than 50
transcript as evidence of completion of at least one year of undergraduate level study (minimum) conducted in English,face to face at an
a
institution located in one of the listed countries*
(b)
Requirements for all categories
IELTS Academic Test result ONLY
merican Samoa, Australia, Botswana, Canada, Fiji, Ghana, Guyana, Ireland, Jamaica, Kenya, Lesotho, Liberia, New Zealand, Nigeria,
A
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.
PL
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 2017
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.
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, after 1 January 2015, an Australian Government administered scholarship and/or fellowship?
Yes
No
Commencement date
AM
3. Have you completed any other scholarship or awards?
Completion/Expected completion date
Yes
No
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
Scholarships/Awards
Institution
Country
Year Awarded
University Medalist
Hitotsubashi University
Japan
2009
President's Scholarship
Simon Fraser University
Canada
2010
Merit Scholarship
Hitotsubashi University
Japan
2011
EX
Memberships
Membership
Country
Membership type
Engineers Without Boarders
Japan
Member
Hitotsubashi Engineers Society
Japan
Executive Member
Publications
Author(s): H. Suzuki
Publication title: A Guide to Modern Engineering
Publisher/Journal title: Engineers Monthly
Language of Publication: Japanese
Year of Publication: 2010
Author(s): H. 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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Endeavour Scholarships and Fellowships Application
8. EMPLOYMENT HISTORY
Please provide details of relevant employment history beginning with your current or most recent employment.
Job Title
Employer Name
Senior Project Manager Ishida & Associates Pty Ltd
Country of Employment
Start month and year
End month and year
Japan
02/2014
07/2016
Ishida & Associates Pty Ltd
Japan
03/2010
01/2014
Administrate Assistant
New Design Engineering
Canada
05/2008
11/2009
Project Manager
9. REFEREES
Title:
Organisation:
Email:
First name:
Ms
Rebecca
Ishida & Associates Pty Ltd
[Link]@[Link]
PL
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.
Last name:
Position:
Frost
Chief Engineer
Phone: +
81 323 122 3215
(Please include country and area codes)
Organisation:
Email:
Prof
First name:
Tatsuke
AM
Title:
Hitotsubashi University
[Link]@[Link]
Last name:
Position:
Yamada
Dean, Department of Engineering
Phone: +
81 323 196 1347
(Please include country and area codes)
10. HOST NOMINATION
To be completed by Endeavour Executive Fellowship, QE II and Endeavour Research Fellowship (including Indigenous Fellowship)
applicants only.
Mr
First name:
Michael
EX
Title:
Organisation:
Email:
The University of Sydney
M.Smith_@[Link]
Last name:
Position:
Smith
Senior Researcher
Phone (Business): +
61 2 8435 9946
(Please include country and area codes)
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11. PROGRAMME SUPPORTING STATEMENT
Please provide details of how your proposed programme would further your academic and/or professional career (maximum 200 words).
My proposed programme will allow me to .....
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 countries (maximum 200 words).
AM
12. PERSONAL STATEMENT
PL
My proposed programme will foster ongoing collaboration by .....
Please explain how receiving an Endeavour scholarship or fellowship would make a difference to your personal life (maximum 200 words).
EX
I strongly believe that .....
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Endeavour Scholarships and Fellowships Application
13. SUPPORTING DOCUMENTS CHECKLIST
Please refer to the Applicant Guidelines to ensure that your supporting documents meet the scholarship and fellowship requirements.
To be eligible applicants must:
scan and attach their supporting documentation specified for the category for which they are applying (see table below and section
9.1-9.11). Applications that do not contain the necessary documentation will be deemed incomplete and therefore ineligible and will not
be considered further
provide an English translation if the original document is not in English
provide certified (attested) copies of:
- Passport, Birth Certificate, National ID card or Australian Citizenship Certificate
- Academic transcripts
- IELTS, TOEFL, CAE or PTE results.
To certify a document:
1. copy the original document
2. p
resent the photocopy and original to a professional person or someone well-respected in your community (of good standing). This could
include but is not limited to: university dean or course convener, teacher, work supervisor, lawyer, doctor, civil servant, Justice of the Peace,
Commissioner of Oaths or Public Notary.
the certifier will sight the original against the copy of the document
PL
the certifier will write or use a stamp (if available), I certify that the copy is a true copy of the original document.
the certifier will sign and date under the statement and provide details of their occupation
3. scan the certified copied document (not the original document).
4. attach the document to your application.
The cost of any fees charged by notaries for certification of documents is the responsibility of the applicant.
Australian
applicants
Further details
Postgraduate (Masters and PhD)
VET
Executive fellowship
Research fellowship
Executive fellowship
QEII and Research fellowship
Postgraduate
9.1
9.2
3*
9.3
Formal admission to an Australian institution for 2017
9.4
Enrolment letter(research towards Masters or PhD only)
9.5
PhD conferment (postdoctoral research only)
9.6
9.7
Employment record/cv/resume
9.8
Referee reports x 2
9.9
Host nomination
9.10
AM
Certified copy required
International applicants
EX
Required documents
Passport or Birth Certificate or National ID card
Verification of Aboriginal and/or Torres Strait Islander
Academic transcript
TOEFL, IELTS, CAE, PTE or Transcript
*Australian Indigenous and Torres Strait Islander applicants only
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Endeavour Scholarships and Fellowships Application
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[Link] AND PUBLICITY CONSENTS AND AGREEMENT
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.
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
:(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, film footage, images, and their words, quotes or other comments made by
or attributed to them, in so far as it relates to their participation in, and experience of, the
Endeavour Scholarship and Fellowship.
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):
ssessing applications
a
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;
- 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 Privacy Principle 8.1 will not apply if the Personal Information is viewed or
used by an individual or parties located overseas; and
PL
a
dministering the Endeavour Scholarships and Fellowships
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
endeavour@[Link].
Privacy Act 1988
p
romoting 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
c ongratulating 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.
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
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:
-a
n 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.
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
- is not obliged to, and has not represented to me that they will, publish the Material
-d
oes not have to identify me as author of any of the Material which they do publish or
otherwise communicate and
- may edit the Material prior to publication as it sees fit without first checking with me.
By submitting an application, I understand and agree that if I am successful and accept
an Endeavour Scholarship or Fellowship:
the departments contractors and agents
Australian universities and participating Australian organisations and
O
ther 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 endeavour@[Link].
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.
EX
I agree that the department:
For information on the departments 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 [Link]/privacy or request
a copy of the privacy policy from privacy@[Link].
I will provide the department, through Scope Global, 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
I will undergo a police check before my offer is confirmed (Australians only)
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), the department may collect and publish images, photos, film footage,
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 applicants
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:
a
s, or as part of, any book, newspaper advertisement or article
television advertisement or programme
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@
[Link] 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).
r adio advertisement or programme and
o
n the internet and in any other media.
Signature
Hiro Suzuki
Date (dd/mm/yyyy)
09/06/2016
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).
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