Australia Awards Scholarships

Split-Site Master’s Program

Expression of Interest
Please attach an additional page if there is insufficient space on this form.

1. What is the name of your organisation?

2. What is the name, position title and contact details for the person coordinating the proposed
Split-Site (Dual Degree) Master’s Program?
Name:
Position:
Organisation:
Work phone:
Mobile phone:
Email:
Fax:
3. What is the name, position title and contact details for your organisation’s supporting Liaison
Officer/s?
Name:
Position:
Organisation:
Work phone:
Mobile phone:
Email:
Fax:
4. What are the names and position titles of personnel within your organisation in the
Human Resource department who will be responsible for supporting the Split-Site Program?
Name:
Position:

Name:
Position:

Name:
Position:
5. What Split-Site Master’s Program is your organisation proposing?

Australia Awards in Indonesia

Gedung Wirausaha, 7th Floor, Jalan HR Rasuna Said, Kav C-5, Kuningan, Jakarta 12940
Tel: +62 (21) 527 7648, Fax: +62 (21) 527 7649 info@australiaawardsindonesia.org
www.australiaawardindonesia.org
 What is the priority area of study being proposed for the split-site program?

If known, what are the names of the Indonesian and Australian universities proposed for this split site
program?

Please provide further details on the courses of study being offered by both Indonesian and Australian
universities. Additional documents may be attached.

How did you identify this split site program and how does it meet the needs of your organisation?

What are the contributions anticipated by your organisation, as a result of scholars returning from the
proposed split site program?

How will you identify participants for this split site program? (including social and geographic
representation)

How would you think a preparatory English preparation course is best encompassed in this program?

What is your proposed timeline for this program?

Please provide information on the Government of Indonesia’s budget allocation for the proposed program.

What is your strategy to conduct monitoring, evaluation and reporting on the proposed program?

6. Is there any additional information that your organisation wishes to submit?

7. Authorisation

Signed:

Full name:
Position:
Date:

Please attach a copy of any documents (e.g. agreement, memorandum of

understanding, etc.) that formalise the arrangements between nominated
universities.
After completing this form, please send by email to
infotl@australiaawardsindonesia.org.

Australia Awards in Indonesia

Gedung Wirausaha, 7th Floor, Jalan HR Rasuna Said, Kav C-5, Kuningan, Jakarta 12940
Tel: +62 (21) 527 7648, Fax: +62 (21) 527 7649 info@australiaawardsindonesia.org
www.australiaawardindonesia.org
 Australia Awards in Indonesia
Gedung Wirausaha, 7th Floor, Jalan HR Rasuna Said, Kav C-5, Kuningan, Jakarta 12940
Tel: +62 (21) 527 7648, Fax: +62 (21) 527 7649 info@australiaawardsindonesia.org
www.australiaawardindonesia.org