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Bi-Centennial Scholarship

Fund

Template application form for Bicentennial Scholarship


Program

Who should complete this form?


Please complete this form if:
 You are a Chilean national who has been awarded a Bicentennial
Scholarship from the Chilean Government under the Bicentennial
Scholarship Fund program; and
 You wish to apply to undertake a Masters or PhD at an Australian
university under the Bicentennial Scholarship Fund program.

How to apply
You must complete this application form in English and attach authorised
copies of all required documentation and send this application form to the
Bicentennial Fund:

Name: Contact details for the fund here


Address:
Email:
Fax:
Telephone
:

Deadline for applications


The deadline for applications is 31 October 2008 for commencement in
Australia in February 2009.

What happens next?


This application will be sent to Universities Australia and be passed on to
the university that you selected as your first preference. If your application
to the university is successful, that university will notify you on the next
steps for enrolment and any other requirements.
If your application to that first preference university is not successful the
application form will be sent to your second then third preferences. If you
are successful you will be notified by that university by 30 November
2008.

Bicentennial Scholarship Program Application Form 1


If your application is not accepted by any of your preferred universities,
you will be notified by the office of the Bicentennial Fund in Chile.
If you have any questions regarding this application or the Bicentennial
Scholarship Fund Program in general, please contact the Bicentennial
Fund.
Advice from potential supervisors
You will be allowed to apply to up to three universities under this
Bicentennial Scholarship program. You are encouraged to contact
academic staff of the appropriate faculty at your preferred university
before submitting your application. These academic staff members can
provide you with assistance concerning your choice of topic. In addition,
they can advise on the preparation of the research proposal.

Complete all sections of this application form


Please ensure that you complete all sections of the form in English. Please
make sure you submit all required documentation:
Authorised copies of the following documents are required*:
o Proof of any changes of name (for example: marriage certificate).
o Transcripts of all tertiary education studies. These should indicate
the name of the qualification, the university of enrolment, the years
of study, the subjects/units undertaken, the grades achieved,
explanatory notes concerning grades, and proof that the
qualification has been completed.
o English language proficiency.
o Copies of the title page and list of Editorial Board members for any
research publications that you have produced.
o A Research Proposal in English (maximum of two A4 pages).
o Two (2) completed referee report forms in English.

(*an authorised copy is a certified copy which a person able to sign


affidavits (for example a pharmacist, medical doctor, Justice of the Peace,
dentists, solicitor, Member of Parliament, school principal, etc) has
certified as a true copy of the original document.)

Privacy statement
Australian universities are subject to the provisions of the Commonwealth
Privacy Act 1988 and you are entitled to the protection of your privacy.
This means that any information that the university collects about you,
including personal details, academic progress, and personal welfare
information, is treated by the university according to strict guidelines.
Access to your information is restricted to those staff that may need

Bicentennial Scholarship Program Application Form 2


information in order to carry out their responsibilities in your personal
and/or academic interests.
Other than in accordance with any legal or academic obligation, the
university will not disclose personal information about you. This means the
university will not release any information about you such as your address,
or your results, even to close relatives, without your permission.
Each university will advise of its privacy guidelines once your application
has formally been accepted by that university.

Personal Information

Title: Mr / Ms / Mrs / Miss / Dr /


Other:
Family
Name:
Given
Name(s):
Date of
Birth:
Gender: Former name if applicable (for
example maiden name before
marriage)#

# NOTE: if qualifications were gained in former name, certification of the


name change must be provided.

Your contact details in Chile:

Address:
Phone (day):
Phone
(evening):
Mobile:
Email
address:

If your contact details will change while this application is being processed
we need to know your future contacts:

Address:
Phone (day):

Bicentennial Scholarship Program Application Form 3


Phone
(evening):
Mobile:
Email
address:
Date of
change:

Permanent address in Chile (if different from above)

Address:
Phone (day):
Phone
(evening):
Mobile:
Email
address:

Bicentennial Scholarship Program Application Form 4


Citizenship Information
Country of
Birth: Visa Type:

Citizenship /  Diplomatic
Country of
Passport:  Dependent
 Student
Visa number:
 Other (please specify)

Have you applied for a


Permanent
Resident Visa to Australia?
Country of
Permanent
Residence:  Yes  No

English Language Proficiency


You need to have achieved a minimum IELTS1 of 6.5 in order to begin
studying your post-graduate qualification.
If you have not reached the minimum IELTS of 6.5 you may be granted
conditional acceptance to post graduate study at an Australian university.
Your scholarship will fund English language training courses in Chile and
up to six months of English language tuition in Australia to meet the
required minimum IELTS of 6.5.

Date of IELTS
test:
Results:
(attach certified
copy)

Was English the language of instruction for any of your previous studies?
 Yes  No

If yes:
Name of
university:
Course
undertaken:
Date of
completion:

1
It will be also acceptable the TOEFL with the corresponding 6.5 IELTS english proficiency
test.

Bicentennial Scholarship Program Application Form 5


Proposed University of study (List three universities in order of your
preference)

Preference 1:
Preference 2:
Preference 3:

Proposed level of Study


 Masters  Doctorate

Proposed field of study (fields of study available under this program are
listed below)
 Mining
 Agriculture and food industry
 Aquaculture and fishing
 Tourism and hospitality
 Biotechnology
 Information and communication technologies
 Energy
 Environmental issues
 Health
 Education
 Housing and public security
 Other
(Other fields must be agreed by mutual written consent of the Chilean
Government and nominated university)

Research Proposal

Title:
Research
question:

Please attached a research outline (maximum of two A4 pages in English)


to this application.

Do you propose to carry out research work off campus?  Yes  No

If yes, please specify where you plan to carry out your research:

Bicentennial Scholarship Program Application Form 6


Off-campus
location:

Proposed Supervisor or academic contacts, if known:


University:
Faculty / School:
Supervisor’s
name:

Proposed start
date:

Bicentennial Scholarship Program Application Form 7


Previous Qualifications (obtained over the pervious 5 years)

Degree or Research or University Grade/ Years Language


Qualification Coursework Result attended of
instruction
Sample – Coursework Flinders Pass 2004-2006 English
Bachelor of University
Psychology

(Please attached certified copies of all qualifications/transcripts)

Are you currently studying?  Yes  No

If yes:
Name of university:
Course undertaken:
Expected Date of
completion:

Marital status
 Single
 Married
 Other

Dependent children
Number:
Age(s):

Previous Australian Government and/or postgraduate scholarships you


have held
Name of award:
Duration:
Value (if currently held):

Bicentennial Scholarship Program Application Form 8


Bicentennial Scholarship Program Application Form 9
Post graduate research experience (last five years only)
Please describe briefly any postgraduate research experience you have
had over the last five years, whether for higher degree purpose or
otherwise, e.g. research projects you have undertaken, work as a research
assistant, presenting research at a conference etc (if insufficient space,
please attached further information - one page maximum).

Employment history
If you are using work experience as an entry requirement you must supply
verified or original documentation from your employer and detailed
resume. It is the applicant responsibility to provide proof of their work
experience and the relevance of that experience to their proposed higher
degree research program (if insufficient space, please attached further
information - one page maximum).

Publications (last five years only)


Please list publications you have produced in the last five years (if
insufficient space, please attached further information - I page maximum).
Do not provide copies of the publications. Please include full bibliographic
reference for publications and indicate whether the publication was
refereed. Where publications are jointly authored, indicate percentage of
your contributions. Please enclose the titlepage for each publication, and
where possible, include the Editorial Board for the publication. Without
sufficient evidence, publications cannot be taken into account.

Bicentennial Scholarship Program Application Form 10


Referees
All applicants must provide two referee reports in English. The university
will not request reports on your behalf.

Referees must be qualified to speak with knowledge about your work


during the qualification most relevant to this application and on your
capacity for research. If you are also basing this application on relevant
work experience /training, at least one of your referees must be able to
comment on you relevant experience.

You must also provide contact details of your referees on this application
form and ask them to complete the referee report form (below) and
attached it to this application.

If you are unable to attach the report to this application please send it to:

Name: Contact details for the fund here


Address:
Email:
Fax:
Telephone
:

This Application is Due to the Bicentennial Fund by 31 October 2008.


Please note it is your responsibility to ensure that the referee reports are
received by the deadline of 31 October 2008. If you do not submit the
reports by this date your application will not be considered.

Referee contact details 1


Name:
University:
Position:
Address:
Email:
Fax:
Telephone
:

Referee contact details 2

Bicentennial Scholarship Program Application Form 11


Name:
University:
Position:
Address:
Email:
Fax:
Telephone
:

Bicentennial Scholarship Program Application Form 12


Declaration
By signing this document:

o I understand that giving false or misleading information is a serious


offence under the criminal code (Australian Government).

o I certify that I have read and understood the questions on this form
and that the answers are true and correct.

o I understand that the university may vary or cancel any decision


made on the basis of incorrect or incomplete information provided
by me. If any information is discovered to be untrue or misleading in
any respect I consent to the university collecting, storing and
disclosing this information to Universities Australia, and Universities
Australia member university, the Australasian Conference of Tertiary
Admission Centres, and any other relevant authority.

o I authorise the university or obtain official records from any


university I have attend.

o I agree to abide by the conditions of award and conditions of


scholarship which may be amended from time to time by the
university.

Signed:

Date:

Bicentennial Scholarship Program Application Form 13