AUSTRALIAN BICENTENNIAL SCHOLARSHIPS AND FELLOWSHIPS SCHEME

SCHOLARSHIP - APPLICATION FORM

1. Full Name___________________________________________________________________________
(please underline surname)

2. Date of Birth_____________________ 3. Nationality _________________

4. Address (for correspondence)____________________________________________________________

______________________________________________________________________________________

Tel no: _______________________ Fax no:_____________________ Email:________________________

5. Academic Qualifications, including results obtained___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

6. Institution, degree, and subject(s) for which currently registered ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you studying full ____ or part-time ____?
When do you expect to complete this degree? _________________________

7. Present Supervisor: ____________________________________________________________________

8. Proposed host University in Australia ______________________________________________________

9. Contact name and department in host University ______________________________________________

10.Period of time it is proposed to spend in Australia (give dates if possible) ___________________________
(give dates if possible)

11. Do you have any other institutional financial support? (Please specify)

_______________________________________________________________________________________

12. Amount Required - please give estimated cost of fares, and estimated maintenance/living expenses during the course of your visit and proposed itinerary
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________TOTAL:___________________

13. References on academic ability and character. Please complete the attached reference request form and send the forms to your referees (NB deadline for receipt of references is 4 June). Write referees' names and addresses here:

a) _____________________________________________________________________________________
_______________________________________________________________________________________

b) _____________________________________________________________________________________
_______________________________________________________________________________________

c) _____________________________________________________________________________________
_______________________________________________________________________________________

14. Please attach to this application (appropriately identifying each item)

1. A curriculum vitae (including academic record)
2. A statement on the nature of your proposed dissertation;
3. A statement from the proposed host institution in Australia that you would be welcome as a visitor there and would be given appropriate supervision;

Signature __________________________________________Date ___________________________

Return completed form and attachments to the Secretary, Sir Robert Menzies Centre for Australian Studies not later than 4 June 1999.