RUILI Conservation Intensive Application Please leave this field empty. Required fields denoted with an asterisk * PRIVACY STATEMENT The personal information you provide in this form is governed by the Privacy and Personal Information Protection Act 1998, the Health Records and Information Privacy Act 2002 and CSU’s Privacy Management Plan (the Privacy Legislation). Your information will be collected by International Internships and UTAS in order to assess your application for entry into the program as well as funding available through the Australians Department Mobility Funding Programs. Your personal information will not be made available to any other person or organisation for any purpose other than the program you are applying for without your consent (except where International Internships and UTAS may be legally required to do so). The provision of personal information in this form is voluntary. GUIDELINES FOR APPLYING If you wish to gain academic credit or receive a New Colombo Plan grant for this program, you must enrol in unit HUM107 at UTAS before you apply. To do this, please contact your Faculty/Enrolment Officer, as only they can enrol you into the unit. If they need further information, you can refer them to http://www.utas.edu.au/arts-law-education/study/overseas-study/cale-short-programs/indonesia-field-trip or contact the unit coordinator, Dr Taufiq Tanasaldy (taufiq.tanasaldy@utas.edu.au). Non-UTAS students who would like to obtain a study credit (0.125 EFTSL) will need to enrol in HUM107 at UTAS as cross-institutional students. If HUM107 does not fit into your degree, or you do not wish to enrol, you can still apply for the program and participate as a private student. In this case, you will need to pay the program cost privately. Personal Details TitleMRMSMx First Name Last Name Preferred Name Contact Number 1 Contact Number 2 Nationality Email Address 1 Email Address 2 Are you an Australian citizen or permanent resident?* —Please choose an option—Yes, I am an Australian citizenYes, I am an Australian permanent residentNo Gender * MaleFemaleUndefined Postal Address Number and Street City State Postcode CountryArubaAfghanistanAngolaAnguillaÅland IslandsAlbaniaAndorraUnited Arab EmiratesArgentinaArmeniaAmerican SamoaAntarcticaFrench Southern TerritoriesAntigua and BarbudaAustraliaAustriaAzerbaijanBurundiBelgiumBeninBonaire, Sint Eustatius and SabaBurkina FasoBangladeshBulgariaBahrainBahamasBosnia and HerzegovinaSaint BarthélemyBelarusBelizeBermudaBolivia, Plurinational State ofBrazilBarbadosBrunei DarussalamBhutanBouvet IslandBotswanaCentral African RepublicCanadaCocos (Keeling) IslandsSwitzerlandChileChinaCôte d'IvoireCameroonCongo, Democratic Republic of theCongoCook IslandsColombiaComorosCabo VerdeCosta RicaCubaCuraçaoChristmas IslandCayman IslandsCyprusCzechiaGermanyDjiboutiDominicaDenmarkDominican RepublicAlgeriaEcuadorEgyptEritreaWestern SaharaSpainEstoniaEthiopiaFinlandFijiFalkland Islands (Malvinas)FranceFaroe IslandsMicronesia, Federated States ofGabonUnited Kingdom of Great Britain and Northern IrelandGeorgiaGuernseyGhanaGibraltarGuineaGuadeloupeGambiaGuinea-BissauEquatorial GuineaGreeceGrenadaGreenlandGuatemalaFrench GuianaGuamGuyanaHong KongHeard Island and McDonald IslandsHondurasCroatiaHaitiHungaryIndonesiaIsle of ManIndiaBritish Indian Ocean TerritoryIrelandIran, Islamic Republic ofIraqIcelandIsraelItalyJamaicaJerseyJordanJapanKazakhstanKenyaKyrgyzstanCambodiaKiribatiSaint Kitts and NevisKorea, Republic ofKuwaitLao People's Democratic RepublicLebanonLiberiaLibyaSaint LuciaLiechtensteinSri LankaLesothoLithuaniaLuxembourgLatviaMacaoSaint Martin (French part)MoroccoMonacoMoldova, Republic ofMadagascarMaldivesMexicoMarshall IslandsNorth MacedoniaMaliMaltaMyanmarMontenegroMongoliaNorthern Mariana IslandsMozambiqueMauritaniaMontserratMartiniqueMauritiusMalawiMalaysiaMayotteNamibiaNew CaledoniaNigerNorfolk IslandNigeriaNicaraguaNiueNetherlands, Kingdom of theNorwayNepalNauruNew ZealandOmanPakistanPanamaPitcairnPeruPhilippinesPalauPapua New GuineaPolandPuerto RicoKorea, Democratic People's Republic ofPortugalParaguayPalestine, State ofFrench PolynesiaQatarRéunionRomaniaRussian FederationRwandaSaudi ArabiaSudanSenegalSingaporeSouth Georgia and the South Sandwich IslandsSaint Helena, Ascension and Tristan da CunhaSvalbard and Jan MayenSolomon IslandsSierra LeoneEl SalvadorSan MarinoSomaliaSaint Pierre and MiquelonSerbiaSouth SudanSao Tome and PrincipeSurinameSlovakiaSloveniaSwedenEswatiniSint Maarten (Dutch part)SeychellesSyrian Arab RepublicTurks and Caicos IslandsChadTogoThailandTajikistanTokelauTurkmenistanTimor-LesteTongaTrinidad and TobagoTunisiaTürkiyeTuvaluTaiwan, Province of ChinaTanzania, United Republic ofUgandaUkraineUnited States Minor Outlying IslandsUruguayUnited States of AmericaUzbekistanHoly SeeSaint Vincent and the GrenadinesVenezuela, Bolivarian Republic ofVirgin Islands, BritishVirgin Islands, U.S.Viet NamVanuatuWallis and FutunaSamoaYemenSouth AfricaZambiaZimbabwe University Details Please note that this program is only open to students from one of the RUILI consortium of universities: University of Tasmania; Charles Darwin University; University of New England; and the University of the Sunshine Coast. Which university do you attend? —Please choose an option—University of TasmaniaCharles Darwin UniversityUniversity of New EnglandUniversity of the Sunshine Coast Student ID Number Degree Name Faculty Name Current WAM/GPA/average mark Major 1 Major 2 If you wish to gain university credit for this program, you will need to enrol in the unit HUM107 - "Bringing the World Back Home" at the University of Tasmania. You can still participate in the program without enrolling but you will not be eligible for university credit, support or funding. I have checked that I am have space in my degree and am eligible to enrol in HUM107 * YesNo. I understand that I will not be eligible for the NCP Mobility scholarship. I understand that I can still can attend the program as a private student and pay all the program costs. I understand that I will not receive any study credits for this program. If you wish to be considered for NCP funding then you must satisfy the following criteria: 1. Earning credit for the program; 2. Be an Australian citizen and not possess at the same time an Indonesian citizenship or residency. I confirm that I have satisfy the listed eligibility criteria of the NCP scholarship available and would like to be considered for a grant OR; I wish to apply privately and will not receive a New Colombo Plan grant. Statement of Intent In approximately 100 words please outline why you wish to participate in this program and how you feel your participation will benefit other participants and the success of the program.* Statement of Intent Other Do you speak any Indonesian (Note that this is NOT a requirement of the program)? * NoneBasicModerateFluent How did you hear about this program? *—Please choose an option—A friend who did a program previouslyFrom a course adviserFrom your lecturerLecture visit by an International Internships team member or past participantEmail sent by your universityOnline info provided by your universityOnline SearchOther Terms and Conditions * Please ensure that you have read and understand International Internships' Terms and Conditions (Link opens in a new window) I have read and accept International Internships' Terms and Conditions I understand that I am liable for UTAS subject tuition fees and other UTAS costs while I am on this program I understand and accept that I must comply with the academic rules and regulations in place at the host institution and that any failure to do so may result in my exclusion from the program at my own cost I understand the costs of this program and the cancellation policies outlined in the Booking Conditions Please provide any other information that you think may be of relevance to your application. Other Information Submit
