Submitting

Application
Endeavour Referee Form
Report
2017
2016
The selection process
an
Yourfor theApplication
Endeavour Scholarships and Fellowships are merit-based and referee reports do not guarantee
an offer.
offer.
Please ensure that you have read the Endeavour Scholarships and Fellowships Applicant Guidelines available on the
Endeavour
Referee reports
websitereceived after the closing
before completing dateReturn
this form. will notyour
be considered.
application forms and the required supporting documentation to:
Reports returned directly
Endeavour Management Team to the department will be treated as confidential and will only be made available to the selection
panel and administrators.
Australian Government Department of Education and Training
Referees may be contacted by the selection panel during the selection process.
International Group, GPO Box 9880

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1.
1. APPLICANT DETAILS
APPLICANTCanberra
DETAILS ACT 2601, AUSTRALIA
Incomplete
Title: Mr or late applications will not be accepted
First
First Name:
Name: Hiro Last
Last Name:
Name: Suzuki
1. PERSONAL DETAILS
The Endeavour
Endeavour category
category the
the applicant
applicant is
is applying
applying for:
for:

Application
Gender:
(If
(If known)
2. REFEREE
The
Title: Mr
Endeavour Research
Mr

ID: ERF_PDR_134977_2015

Hiro
Male

First Name:DETAILS
Hiro

Title: Professor
Preferred Name:
First Name: Tatsuke
81 213
Phone: + 81
Female

213 854
854 3719
3719
Fellowship
(Mr, Miss, Ms or Mrs)

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Unspecified

Former Name:
03/02/1982
Date of Birth: 03/02/1982

Suzuki
Last Name: Suzuki

Last Name: Yamada

Cell/Mobile: + 81
81 213
213 865
865 5574
5574
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Position Held: Dean, Department
(Please include of Engineering
country and area codes) Organisation: Hitotsubashi University
(Please include country and area codes)

Phone: +Hiro.suzuki@hotmail.com
Email Address: 81 323 196 1347
Hiro.suzuki@hotmail.com Mobile: 81 323 186 5543
(Please include
(Please include country and area codes)
Alternate Hiro.suzuki@hotmail.com
Hiro.suzuki@hotmail.com
Email Address:
Email: T.Yamada@hitotsubashi.ac.jp

Postal
Postal Address
Address
EQUITY & DIVERSITY
Address Line
Address 1: 2-1 Naka
Line 1:
Are you an Australian Aboriginal or Torres Strait Islander? (Australian applicants only)
Address Line 2: Kunitachi
Yes No Choose not to give
City/Suburb: Tokyo State/Province: Tokyo Prefecture
EX

Do you identify as an indigenous or first nations person of your home country ? (International applicants only)
Postcode: 186-8601 County: Japan
Country:
Yes No Choose not to give
Relationship to applicant Length of relationship
Are you from a non-English speaking background?
Current supervisor 2 3
Yes No Choose not to give Years
Years
Language Japanese
Japanese Months

3. APPLICANT
Do EVALUATION
you have a disability?
Please evaluate the
Yes evaluate the applicant
applicant against the
No against the criteria
criteria below,
below, in
inChoose
terms of
terms of your
your
not experience.
experience.
to give Type
Top 5%
(Example: Top 5% == Excellent,
Excellent, Top
Top 10%
10% == Very
Very Good,
Good, etc.)
etc.)
Unable to
Residential Address Postal Address (tick if same as residential)
Poor Average Good Very Good Excellent comment
(where you are currently living)
Do not complete below if above box is ticked.
Academic/professional achievement
25-10-20 Higashiyama
Address Line 1: 25-10-20 Higashiyama Address Line 1:
Leadership qualities
Address Line 2: Address Line 2:
Personal integrity
City/Suburb: Sendai
Sendai City
City City/Suburb:
Capacity to communicate and relate well to others
State/Province: Miyagi
Miyagi Prefecture
Prefecture State/Province:
Resourcefulness and initiative
Postcode: 980-0856
980-0856 Emotional maturity Postcode:
Country: Japan Adaptability to new situations
Japan Country:
Potential for future contribution in field of study
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Endeavour Scholarships and Fellowships Application

2. CITIZENSHIP AND RESIDENCY

Country of Citizenship Country of Permanent Residency

Japan
Japan Japan
Japan
Do you hold dual citizenship with another country(ies)?

No Yes Country(ies) Canada

Canada

In which country do you propose to undertake your Endeavour scholarship or fellowship?

Australia
Australia

3. PROPOSED PROGRAM

Please indicate the Endeavour scholarship or fellowship you are applying for:

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1. Endeavour Postgraduate Scholarship (international) 4. Endeavour Executive Fellowship

Doctorate Degree (PhD) Professional Development

Masters Degree by Coursework

Masters Degree by Research

Diploma

Advanced Diploma

Associate Degree
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2. Endeavour Vocational Education & Training Scholarship
(international) 5. Endeavour Postgraduate Scholarship (Australian)

Long-term study/research towards an Australian Masters

Long-term study/research towards an Australian PhD

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3. Endeavour Research Fellowship 6. Endeavour QEII Diamond Jubilee Scholarship

Short-term postdoctoral research Long-term postdoctoral research

Short-term research towards a Masters Degree Long-term research towards a doctoral degree

Short-term research towards a Doctorate Degree

Please specify your proposed field of study, research or professional development.

e.g. education, engineering, environment, health, information technology, management
EX

Engineering
Engineering

Proposed host organisation:

University
University of Sydney
of Sydney

01/02/2017
Proposed Start Date: 01/02/2017 01/06/2017
Proposed End Date: 01/06/2017

Home organisation Country of home organisation

Tohoku
Tohoku University
University Japan
Japan

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Endeavour Scholarships and Fellowships Application

3. PROPOSED PROGRAM (CONTINUED)

Please summarise, in words that can be understood by a person outside your field, details of your proposed program, why you chose your
proposed host organisation and what your proposed program is intended to achieve.
Also provide details, including proposed dates and locations of any proposed fieldwork and/or internships (maximum 300 words).

My proprosed
My proprosed program
program will..........
will..........

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4. EDUCATIONAL QUALIFICATIONS

Please provide details of your educational qualifications:

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Please attach a separate list if you have completed more than three qualifications.
PhD
Qualification: PhD
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Tohoku University
Institution: Tohoku University

Japan
Country of enrolment: Japan

Commencement date: 02/04/2014

02/04/2014 Completion/Expected completion date 02/04/2018
02/04/2018

Study Status: Completed Undergoing

Qualification: Masters
Masters of Engineering
of Engineering
Institution: Simon Fraser
Simon Fraser University
University

Canada
EX

Country of enrolment: Canada

Commencement date: 05/06/2010
05/06/2010 Completion/Expected completion date 07/06/2013
07/06/2013

Study Status: Completed Undergoing

5. EVIDENCE OF ENROLMENT OR CONFERMENT

For Endeavour Research Fellowship, Endeavour Postgraduate Scholarship (Australian), Endeavour QEII Scholarship and Endeavour
Research Fellowship for Indigenous Australians applicants only.

I am currently enrolled in a Masters degree and will undertake research while on my Endeavour program towards my Masters.
I am currently enrolled in a PhD degree and will undertake research while on my Endeavour program towards my PhD.

I am currently enrolled in a PhD degree and will complete my PhD before I commence my Endeavour program.

I have completed a PhD and will undertake postdoctoral research as my Endeavour program.

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Endeavour Scholarships and Fellowships Application

6. LANGUAGE REQUIREMENTS/PROFICIENCY

All applicants are required to provide evidence of language ability. Please see the relevant section of the Application Guidelines and submit
the required documentation with your application.

7. SCHOLARSHIPS, AWARDS, MEMBERSHIPS AND PUBLICATIONS

1. Have you previously completed an Endeavour scholarship or fellowship? Yes No

2. Do you currently hold or have you completed an Australian Government administered scholarship and/or fellowship?

Yes No Commencement date Completion/Expected completion date

3. Have you completed any other scholarship or awards? Yes No

4. Please provide details of relevant scholarships and awards, professional memberships and publications.
Please attach a separate list if you have additional scholarships, memberships or publications.
Scholarships/Awards

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Scholarships/Awards Institution Country Year Awarded

University
University Medalist
Medalist Hitotsubashi
Hitotsubashi University
University Japan
Japan 2009
2009
President's
President's Scholarship
Scholarship Simon
Simon Fraser
Fraser University
University Canada
Canada 2010
2010
Merit
Merit Scholarship
Memberships
Scholarship

Membership

Engineers
Hitotsubashi
Without Boarders
Engineers Without Boarders
Hitotsubashi Engineers
Engineers Society
Society
Hitotsubashi

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Hitotsubashi University
University

Country

Japan
Japan
Japan
Japan
Japan
Japan

Membership type

Member
Member
Executive Member
Executive Member
2011
2011
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Publications
Author(s): H. Suzuki,
H. Suzuki,

Publication title: A Guide

A to Modern
Guide to Modern Engineering
Engineering

Publisher/Journal title: Engineers Monthly

Engineers Monthly

Language of Publication: Japanese

Japanese 2010
Year of Publication: 2010

Author(s): H. Suzuki,
H. Suzuki, B.
B. Ishida,
Ishida, H.
H. Johnstone
Johnstone

Advanced Theories
Publication title: Advanced Theories in
in Modern
Modern Engineering
Engineering
EX

Publisher/Journal title: Engineers Digest

Engineers Digest

Language of Publication: English

English Year of Publication: 2014
2014

8. EMPLOYMENT HISTORY

Please provide details of relevant employment history beginning with your current or most recent employment.

Job Title Employer Name Country of Employment Start month and year End month and year

Senior Project
Senior Project Manager
Manager Ishida &
Ishida & Associates Pty Ltd
Associates Pty Ltd Japan
Japan 02/2014
02/2014 07/2016
07/2016

Project Manager
Project Manager Ishida & Associates
Ishida & Pty Ltd
Associates Pty Ltd Japan
Japan 03/2010
03/2010 01/2014
01/2014

Administrate Assistant
Administrate Assistant New Design
New Design Engineering
Engineering Canada
Canada 05/2008
05/2008 11/2009
11/2009

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Endeavour Scholarships and Fellowships Application

9. REFEREES

Please provide details of two referees. It is your responsibility to ensure that referee reports are received by the Endeavour Management
Team by the closing date.

Ms
Title: Ms Rebecca
First name: Rebecca Frost
Last name: Frost

Ishida &
Organisation: Ishida & Associates
Associates Pty
Pty Ltd
Ltd Chief Engineer
Position: Chief Engineer

R.Frost@ishida.co.jp
Email: R.Frost@ishida.co.jp Phone: + 81
81 323
323 122
122 3215
3215
(Please include country and area codes)

Prof
Title: Prof Tatsuke
First name: Tatsuke Yamada
Last name: Yamada

Organisation: Hitotsubashi University

Hitotsubashi University Position: Dean, Department of
Dean, Department of Engineering
Engineering

T.Yamada@hitotsubashi.ac.jp
Email: T.Yamada@hitotsubashi.ac.jp 81 323
Phone: + 81 323 196
196 1347
1347

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(Please include country and area codes)

10. HOST NOMINATION

To be completed only by Endeavour Executive Fellowship, Endeavour Research Fellowship (including REF for Indigenous Australians)
and QEII applicants only.

Mr
Title: Mr

Organisation: The of Sydney

M.Smith_@sydney.edu.au
Email: M.Smith_@sydney.edu.au
Michael
First name: Michael

The University
University of Sydney PL Smith
Last name: Smith

Senior Researcher
Position: Senior

61 2
Phone (Business): + 61
Researcher

2 8435
8435 9946
9946
(Please include country and area codes)
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11. PROGRAM SUPPORTING STATEMENT

Please provide details of how your proposed program would further your academic and/or professional career (maximum 200 words).

My proposed
My proposed program
program will
will allow
allow me to .....
me to .....
EX

Please provide details of how your proposed program will benefit Australia and your potential to foster ongoing collaboration and
cooperation with your home and host countries (maximum 200 words).

My proposed program
My proposed program will
will foster
foster ongoing
ongoing collaboration
collaboration by
by .....
.....

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Endeavour Scholarships and Fellowships Application

12. PERSONAL STATEMENT

Please explain how receiving an Endeavour scholarship or fellowship would make a difference to your personal life (maximum 200 words).

II strongly
strongly believe
believe that
that .....
.....

13. SUPPORTING DOCUMENTS CHECKLIST

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Please refer to the Applicant Guidelines to ensure that your supporting documents meet the scholarship and fellowship requirements.

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EX

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Endeavour Scholarships and Fellowships Application
14.PRIVACY AND PUBLICITY CONSENTS AND AGREEMENT

Privacy Act 1988
The Department of Education and Training (the department) and its contractors are
bound by the provisions of the Privacy Act 1988 (Privacy Act). Schedule 1 of the
Privacy Act outlines the Australian Privacy Principles (APPs), which prescribe the rules
for handling personal information, including sensitive information.
Personal Information is defined by section 6 of the Privacy Act as: information or an
opinion about an identified individual, or an individual who is reasonably identifiable
:(a) whether the information or opinion is true or not, and(b) whether the information or
opinion is recorded in a material form or not.
The department collects Personal Information from applicants in order to assess their
applications and administer the Endeavour Scholarships and Fellowships. Applicants
are not required to provide Personal Information to the department but without collecting
Personal Information the department will not be able to process an application or
administer the Endeavour Scholarships and Fellowships for successful applicants.
The department will also collect Personal Information from successful applicants over
the duration of their Endeavour Scholarship and Fellowship, including their image in
photographs, film footage, images, and their words, quotes or other comments made by
or attributed to them, in so far as it relates to their participation in, and experience of, the
Endeavour Scholarship and Fellowship.
Personal Information (including sensitive information) provided to the department by
Applicants are not required to provide their consent to the collection and publication of
Materials as described in this Publicity Notice and may withdraw their consent at any
time, prior to the publication of the Material, by contacting the department in writing at
endeavour@education.gov.au.
Privacy and Publicity Consents and Agreement
By submitting an application:
I consent to my Personal Information (including sensitive information) provided to,
and collected by, the department in relation to applications under the Endeavour
Scholarships and Fellowships being used for the Purposes and disclosed to the
recipients as described in the Privacy Notice
I understand that the department will not provide individual feedback if my application
is unsuccessful. I will be provided with generic reasons why many of the Endeavour
Scholarship Fellowship applications do not receive an offer via the Endeavour website
at the conclusion of the round
I understand that if my Personal Information is disclosed and/or published on the
internet as described in this Privacy Notice:
my Personal Information will be available to the public on the world wide web and may
be viewed by members of the public in Australia and/or individuals or parties located
overseas;

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applicants (including Personal Information collected by the department from successful
applicants over the duration of the Endeavour Scholarships and Fellowships) will only
be used by the department for the following purposes (the Purposes):
assessing applications
administering the Endeavour Scholarships and Fellowships
- the department will have no control over who views my Personal Information
published on the internet or how a member of the public may use the Personal
Information;
- Australian Privacy Principle 8.1 will not apply if the Personal Information is viewed or
used by an individual or parties located overseas; and
- an individual or parties located overseas will not be accountable under the Privacy

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promoting the Endeavour Scholarship and Fellowships, including in promotional
material, photographs, audio visual, media releases, information and publications in
hardcopy and/or on the internet and
congratulating and/or inviting successful recipients and alumni to functions and events
held in Australia and overseas.
Please note, any Personal Information that is used in promotional materials and/or
published on the internet will be available to the public (including on the world-wide web)
and may be viewed by members of the public in Australia and/or individuals or parties
located overseas. The department will have no control over who views the Personal
Information published on the internet or how a member of the public may use the
Personal Information.
The department may disclose personal information in relation to applications under the
Endeavour Scholarships and Fellowships for the Purposes listed above to the following
Act and as a result I will not be able to seek redress under the Privacy Act for any
privacy breaches committed by the individual or parties located overseas.
I agree that the Material may be used by the department for the purpose or promoting
the Endeavour Scholarship and Fellowships at any time in the future, even if
information about me in the Material (such as my employment status) has ceased to
be true
I understand and agree that I will not receive, and am not entitled to receive, any
payment for the use, disclosure or publication of the Material
I grant, to the extent (if any) that I own intellectual property rights in the Material or any
part of the Material, a perpetual, world-wide and royalty-free licence to the department
and its Agents to copy and disseminate the Materials in accordance with this Publicity
Notice
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recipients: I agree that the department:
Australian Government Departments and agencies, including but not limited to - is not obliged to, and has not represented to me that they will, publish the Material
Austrade, the Department of Foreign Affairs and Trade, the Department of Immigration
and Border Protection, the Australian Federal Police and the Department of Prime - does not have to identify me as author of any of the Material which they do publish or
Minister and Cabinet otherwise communicate and

Australian Parliamentarians and Parliamentary committees - may edit the Material prior to publication as it sees fit without first checking with me.

the departments contractors and agents By submitting an application, I understand and agree that if I am successful and accept
an Endeavour Scholarship or Fellowship:
Australian universities and participating Australian organisations and
I will provide the department, through Scope Global, regular reports on my progress
Other individuals or parties located overseas who may access Personal Information and a final report at the completion of my program
published in promotional materials and/or on the internet.
I will act in a manner befitting a recipient of an Endeavour scholarship or fellowship
Applicants are not required to provide their consent to the collection, use and disclosure
of Personal Information as described in this Privacy Notice and may withdraw their I will use the funds for the purposes granted
consent in writing by contacting the department at endeavour@education.gov. I will acknowledge the assistance given by the Australian Government in any written
au. However, this will mean that the department may not be able to consider their
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reports, publications or publicity

application and/or administer and promote the Endeavour Scholarship and Fellowships.
For information on the departments privacy policy, including information on how the
department handles personal information, how someone can access or correct personal
information, or how to make a complaint, go to www.education.gov.au/privacy or request
a copy of the privacy policy from privacy@education.gov.au.
I will undergo a police check before my offer is confirmed (Australians only)
I consent to the collection, use and disclosure of my Personal Information, in the
manner described in the Privacy Notice for the duration of my Endeavour Scholarship
and Fellowship

Publicity Notice I agree and consent to the publication of Material as described in the Publicity Notice

For the purpose of promoting the Endeavour Scholarships and Fellowship Program I have the right to withdraw my consent to the publication of the Material on the
(Program), the department may collect and publish images, photos, film footage, internet at any time prior to the publication of the Material, by contacting endeavour@
words, quotes or other comments made by or attributed to successful applicants, education.gov.au in writing.
and any other Personal Information about successful applicants (including sensitive Terms and Conditions
information), collected in connection with the Program (together, the Material). The
department may collect the Material during the term of the successful applicants I declare that I have read and understood the Privacy Notice above
Endeavour Scholarship and Fellowship, and use and publish the Material for the I declare that I have read and understood the Publicity Notice above
purpose of promoting the Program, at any time.
I declare that I have read and understood the Privacy and Publicity Consent and
The department may disclose the Material to any person or organisation, including Agreement Statement above
without limitation by publishing it:
I declare that the contents of my application are true, and
as, or as part of, any book, newspaper advertisement or article
I acknowledge that giving false or misleading information is a serious offence under
television advertisement or program the Criminal Code (Commonwealth).
radio advertisement or program and
on the internet and in any other media.

Signature Date (dd/mm/yyyy)

Hiro Suzuki
Hiro Suzuki 09/06/2016
09/06/2016 PRINT FORM
Print Form

* 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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