Australian Government

Endeavour Leadership Program Nomination Form

• Nominations are to be made by the applicants host organisation(s). The person completing this form must hold a senior
s
position within the host organisation.
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available to the selection panel and administrators. elp.enquiries@scopeglobal.com

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• The selection process for the Endeavour Leadership Program is merit-based and nominations do not guarantee an offer.
Nominations received after the closing date will not be considered.
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selection panel and administrators.

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• Information for potential host organisations can be found on the Endeavour
deavour Leadership Program website.

1. APPLICANT DETAILS

Title: Mr

First Name: Hiro Last Name: Suzuki

Application ID: Research_226007_2019

The Endeavour Leadership Program category the applicant

nt is applying
app for:
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Research

Executive

Postgraduate (Australian)
ustralian)
tralian)

2. NOMINATING ORGANISATION
SATION DETAILS
DETAI

Title: Mr

First Name: Michael Last Name: Smith

d Senior Researcher
Position Held:
d: Organisation: The University of Sydney
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Phone + 61 02 8435 9946

Phone: Email: m.smith_@sydney.edu.au
(Please
ase include country area codes)
countr and a

Posta Address
Postal
Address
dress Line 1: 38 University Road

Address Line 2: The University of Sydney

City/Suburb:
b: Sydney State/Province: NSW

Postcode: 2006 Country: Australia

Have you discussed the proposed dates with the applicant?

Yes No

Endeavour Leaders must commence between 1 January and 30 November of round year. Please check the Endeavour Website for minimum and
maximum durations. http://internationaleducation.gov.au/endeavour

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Endeavour Leadership Program Nomination Form

3. PROPOSED LEADERSHIP ACTIVITY

In your own words, please provide a brief summary of the proposed leadership activity (maximum 300 words)

The applicants program will........

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How will the proposed leadership activity build or improve the linkages
(maximum 100 words)
s between the home and host organisat

The applicants proposed program will improve the linkages between........

organisations?
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(maximum 100 words)

The organisation has decided to nominate this applicant because of......

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Endeavour Leadership Program Nomination Form

3. PROPOSED LEADERSHIP ACTIVITY (continued)

Is the applicant’s language ability suitable to undertake the proposed Leadership Activity at your organisation?

Yes No Please note, if this box is ticked the applicant will be deemed ineligible and their application will
not be considered further.

Signature Date (dd/mm/yyyy)

Michael Smith 09/09/2018 PRIN FORM

PRINT

* 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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APP 5 Privacy Notice

The Endeavour Leadership Program (the Program) is the Australian Government’s two way mobilityy program for short and long term study, res research and
rtment of Education and Training (the d
professional development with Australia’s priority partner countries. The Australian Government Department department)
(GPO Box 9880, Canberra ACT 2601, phone: 1300 566 046) and its contractors manage personal sonal and sensitive information collected for the Program
in accordance with the Privacy Act 1988 (Privacy Act). Any personal information collected in n relation to applications under the Program will be used for

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assessing applications for, and the administration of, the Program. Personal information provided to the department will not be used for any other purpose
and is usually disclosed only to the department’s contractor. The department will not disclose your personal information to any oth
other person or entity (in-
vacy Act, or you have given consent for the d
cluding an overseas entity) unless such disclosure is permitted pursuant to the Privacy disclosure.

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sed in promotional materials and/or published
to, you in so far as it relates to the Program. Personal information that is used publishe on the internet will be available to
the public (including on the worldwide web) and may be viewed by members mbers
bers of the public in Australia
Austra and/or individuals
individu or parties located overseas. The
department will have no control over who views your personal informationationn published on the internet
interne or how a member
mem of the public may use your personal
information. By completing and submitting this form, you agree thatt APP 8 does not bind the department.
departm a
You also understand that an individual or party
located overseas will not be accountable under the Privacy Act and as a result ult you will not be able to seek
se redress
r under the Privacy Act for any privacy
seas
breaches committed by the individual or parties located overseas

ersonal information is that the department may

The consequence of not providing some or all of your personal m not be able to process the application or administer
M
epartment
ment may not be able to contact you about
the Program for successful applicants. Further, the department ab your participation as a host.

cy, including information

For information on the department’s privacy policy, formation on how the department
departm
dep handles personal information, how someone can access
ke a complaint, go to www.education.gov.au/privacy
or correct personal information, or how to make www.education.gov.au or request a copy of the privacy policy from privacy@
education.gov.au.
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