EDUCATION/STUDY EMPLOYMENT PROJECT PERSONAL DETAILS APPLICATION FORM CHURCHILL FELLOWSHIP 2017 BEFORE COMPLETING THIS FORM: Please read the information overleaf Preferred Name: Residential Address: Suburb/Town: Postal Address (if different): Tel Work: Tel Home: Email: State: Tel Mobile: Postcode: Australian Citizen Y N Date of birth: Have you previously applied? Y N If yes, year? PROJECT AIM Approx 10-15 words or 100 characters PROJECT DESCRIPTION Overview of project using plain English and clear, simple terms. Dot points may be used. Approx 100 words or 720 characters SPONSORED FELLOWSHIP I would like to be considered for the following Sponsored Fellowship/s: (Leave blank if not relevant to your project) 1) 2) Current position: Current employer: Nature of business: Previous employer: (1) Position held: Previous employer: (2) Position held: Position commenced: (MM/YYYY) Employment commenced: (MM/YYYY) Tel: Date from-to: (MM/YYYY MM/YYYY) Date from-to: (MM/YYYY MM/YYYY) Educational Qualifications (from most recent) Institution Year Completed Are you currently enrolled at any tertiary institution? Y Institution: Are your current studies related to the proposed project? Explain: N If yes, expected completion date: (MM/YYYY) Course: Previous study or research undertaken overseas and when: AWARDS/ACTIVITIES Other awards/grants (title and when awarded): Current community/volunteer activities: APPLICATIONS CLOSE 28 APRIL 2017 Application Form 2017 Page 1 of 4
APPLICATION FORM GUIDELINES Before you fill in the Application Form Read the Churchill Fellowship Information on pages 3-4. Check that you have the current Application and Referee Forms. Applications submitted on forms from previous years will not be accepted. If you are using a paper Application Form, ensure that you have one or two additional copies in case of errors. All sections must be completed. Application Forms with sections left blank or answered with to be advised will not be accepted. Typing is preferred. If you are using paper forms, cutting and pasting or hand printing in block letters using black ink is acceptable. Do not type or write in the margins and keep pasted sections unfolded. Your application MUST be confined to the Application Form. Do not use additional pages unless proof of fees is required. Except for an amount for fees, you do not need to provide any other costs for your application. All costings for your project ie. airfares, living allowances etc. will be completed by the Trust. Ensure you read and fill in each statement in the DECLARATIONS section. Submit one copy of your application and one copy of each reference. Keep a copy of your entire application for your own records. At the time of initial application do not submit CVs, photos, letters of support, presentations or any other documentation. FILLING IN THE FORM PAGE 1 Any questions not explained in detail below are considered self explanatory. PROJECT Project Aim: State the purpose or goal of your project in approximately 10-15 words or 100 characters Project Description: Describe your project in clear, simple terms that will make it easy to comprehend in approximately 100 words or 720 characters. Be succinct and avoid jargon or technical speak. A project description that is diffcult for selection panels and committees to decipher will not enhance your application Sponsored Fellowship: All applicants are automatically considered for a Churchill Fellowship, however you can indicate your interest in being considered for up to two sponsored Churchill Fellowships on the Application Form. Please refer to page 8 in this application pack for the full list of sponsored Fellowships available. A sponsored Fellowship offers the dual benefit of representing the Trust and the sponsor and can provide a higher level of visibility and credibility. The high regard for the sponsor can also increase the opportunity to share your research findings with the Australian community. If your project does not align with any of the sponsored Fellowship descriptions leave this question blank. EDUCATION/STUDY Educational Qualifications: If space is insuffcient limit to most recent or most relevant. Are you currently enrolled at any tertiary institution? If yes, complete the details of your current enrolment including the month and year you expect to complete your studies. Are your current studies related to the proposed project? Explain: A Churchill Fellowship will not be awarded to assist in gaining a tertiary qualification. If your current studies are closely related to your overseas project you will be ineligible for a Churchill Fellowship until after completion of your studies. AWARDS/ACTIVITIES Current community/volunteer activities: For example Scout leader, Neighbourhood Watch, volunteer sports coach/umpire, Red Cross.
APPLICATION FORM CHURCHILL FELLOWSHIP 2017 BEFORE COMPLETING THIS FORM: Please read the information overleaf Town/Nearest Major City/State/Country Name or Type of Institution/Organisation Proposed Research Weeks PROPOSED ITINERARY Total Weeks: Approximate departure date (between March 2018 and February 2019): FEE REQUEST Description of Conference/Course/Fees Required Fees totalling over 1,000 AUD must be accompanied by formal documentation Cost in foreign currency Fee Includes: Meals (M), Accom (A) M Y N A Y N M Y N A Y N M Y N A Y N What experience do you have to undertake the project? Approx 50 words or 350 characters. What new knowledge do you hope to gain overseas and other than your Fellowship Report how will you diseminate the findings to the Australian community? Approx 100 words or 720 characters. REASONS FOR APPLICATION How will your project benefit the Australian community? Approx 170 words or 1190 characters. DEPENDANT'S ALLOWANCE FURTHER DOCUMENTATION WILL BE REQUIRED BEFORE APPROVAL. Request Dependant's Allowance Y N DECLARATIONS ALL DECLARATIONS MUST BE COMPLETED. I have included: 1x Professional Reference 1x Project Reference Documentation for fees totalling over 1,000 AUD Y N/A I have read and accept the Privacy Statement (page 2) and Churchill Fellowship Information (pages 3-4) I understand that my referees may be contacted by the Churchill Trust as part of the selection process I state that all information in this application is true and correct. I accept that the Churchill Trust has the right to reject an application or retract the award of a Churchill Fellowship on the basis of false or misleading information forming any part of a Churchill Fellowship application. Applicant's Signature APPLICATIONS CLOSE 28 APRIL 2017 Date: / / 20 Application Form 2017 Page 2 of 4 T STA
FILLING IN THE FORM PAGE 2 PROPOSED ITINERARY Please be specific as this information is used by the Churchill Trust to cost your itinerary. When completing this section, please consider the following: Limit your itinerary to destinations that will be of most benefit to your project. Overcrowding an itinerary can lead to fatigue and may be of less benefit to project outcomes. The high cost of air travel to some of the more remote countries and the diffculty of internal travel. Avoid high risk countries (listed by the Department of Foreign Affairs) as the Trust will not approve travel to these countries. Your itinerary must be completed in one continuous journey. Town, Nearest Major City, State and Country: If your destination is a small town such as Berkeley in the USA, please list the nearest major city (and state if applicable) as follows: Berkeley, San Francisco, California, USA. If space is insuffcient you may combine visits within one city or region on a single line. Institution/Organisation: Please specify the name or type of organisation or individual you wish to visit (it is not necessary to arrange the visit at this stage). Proposed Research: Brief description, such as interviews, observation, internship, course or conference attendance are acceptable here. Duration: Weeks are 7-day weeks and travelling and rest time must be included. Once the budget for your itinerary is approved any amendments to the original itinerary will be at your own expense. Your itinerary must be no less than four weeks to a maximum of approximately eight weeks. Slightly longer itineraries are not precluded if justified. Approximate Departure Date: If successful you must depart on your Fellowship between 1 September 2015 and 31 August 2016. An exact date is not yet required the month and year in which you wish to depart is suffcient eg. September 2015. To be advised is not an acceptable answer. FEE REQUEST This section is only applicable if you wish to undertake tuition, a specific course or attend a conference applicable to your project where a registration fee is required. Indicate the name of the tuition, course or conference and the expected fee in foreign currency. Requests for fees totalling in excess of 1,000 AUD must be supported by formal documentation at the time of initial application. Fees that are not requested at the time of application will NOT be paid by the Trust if you are awarded a Fellowship. If significant fees are requested the duration of the Fellowship may be reduced. REASONS FOR APPLICATION This section of the Application Form will be used by the panel and committee members to assess the merit of you, your project and the benefit to Australia. You should ensure your answers are clear and concise. What experience do you have to undertake the project? List your experience and knowledge in the field of the project. What new knowledge do you hope to gain overseas and other than your Fellowship Report how will you disseminate your findings to the Australian community? Be specific. Answers in dot point form are acceptable for this question. If successful in your application you are under contract to submit a written report at the completion of the Fellowship. What other avenues are available to you to disseminate the knowledge you gain overseas to the broader Australian community. How will your project benefit the Australian community? Benefit at a local, state or national level should be addressed in this question. DEPENDANT'S ALLOWANCE Please tick Yes or No. Only tick Yes if the following applies: you expect to lose at least 50% of your total household gross family income while you are away, and your dependants will not be accompanying you during any part of your Fellowship or within 3 months of the completion of the Churchill Fellowship programme. For the Trust to consider payment of Dependant's Allowance it must be applied for at the time of your initial application. DECLARATIONS All declarations must be completed.
PROFESSIONAL REFERENCE FORM CHURCHILL FELLOWSHIPS 2017 BEFORE COMPLETING THIS FORM: Please read the information overleaf APPLICANT DETAILS PROJECT AIM (to be provided by the applicant) REFEREE DETAILS Employer: Position: Telephone: Email: Reference must not exceed the space provided below. Approx 400 words or 2800 characters. PROFESSIONAL REFERENCE DECLARAT IONS BY REFEREE ALL DECLARATIONS MUST BE COMPLETED. I agree to being contacted by the Churchill Trust as part of the selection process I state that all information in this reference is true and correct. I accept that the Churchill Trust has the right to reject an application or retract the award of a Churchill Fellowship on the basis of false or misleading information forming any part of a Churchill Fellowship application Referee's Signature Date: / / 20 APPLICATIONS CLOSE 28 APRIL 2017 Application Form 2017 Page 3 of 4
The Winston Churchill Memorial Trust The Winston Churchill Memorial Trust was established in Australia in 1965 shortly after the death of Sir Winston Churchill. The Trust is a not for profit educational institution governed by a Board of Directors who give their time voluntarily. The aim of The Winston Churchill Memorial Trust is to provide an opportunity for Australians to travel overseas to conduct research in their chosen field that is not readily available in Australia. No prescribed qualifications are required and the subject of the proposed project is limitless provided a benefit to Australia is evident. Merit of the proposed project is a key factor and a desire to share the research findings with the Australian community must be displayed. The value to the Australian community of the applicant s work and the extent to which it will be enhanced by an overseas research project are important criteria for the selection of Churchill Fellows. All Churchill Fellowship applicants need to demonstrate: past achievement in the field of their proposed project, and commitment to future contribution in the field of their proposed project. WHAT IS A PROFESSIONAL REFERENCE? Two references from different individuals are required to support each Churchill Fellowship application: one Professional Reference; and one Project Reference. The Professional Reference must be typed or printed clearly on this Professional Reference Form and must fit within the space provided. References provided on letterhead or other paper will not be accepted. This does not apply to the online application process. A Professional Referee is expected to: be an Australian Citizen living in Australia know the applicant in a professional (ie. work related) capacity have some knowledge of the applicant s professional achievements and have some knowledge of the applicant s personal qualities. A Professional Reference should include the referee's knowledge and opinion regarding: the personal and professional qualities of the applicant the professional achievements and merit of the applicant in their profession the applicant s commitment to their profession and how the applicant will benefit professionally from a Churchill Fellowship. INFORMATION FOR REFEREES INFORMATION FOR APPLICANTS If the applicant has not already provided a copy of their application request one to assist you with the completion of your reference. You may paste a typed reference onto the form if it fits within the space provided. If you do so please sign your name in pen on the pasted sheet as verification, then sign your name again at the bottom of the form. If you are unable to complete a reference please contact the applicant promptly so that they may identify another referee. Return your reference to the applicant in plenty of time for them to meet the closing date of 16 February 2015. Your reference cannot be submitted individually. If you have any queries that the applicant is unable to assist you with please call the National Offce of the Trust on 1800 777 231 or 02 6247 8333. Ensure that you have completed the Applicant's Details at the top of the Professional Reference Form. Send this form and a copy of your application to your Professional Referee as early as possible. It is your responsibility to ensure that the reference is completed correctly and returned to you for submission with your application before the closing date. Applications received without one Professional Reference AND one Project Reference will not be accepted. To expedite the return of references to you, consider including a self-addressed, stamped envelope with each Referee Form for your referee to use when returning the completed reference. APPLICATIONS CLOSE 28 APRIL 2017
PROJECT REFERENCE FORM CHURCHILL FELLOWSHIPS 2017 BEFORE COMPLETING THIS FORM: Please read the information overleaf APPLICANT DETAILS PROJECT AIM (to be provided by the applicant) REFEREE DETAILS Employer: Position: Telephone: Email: Reference must not exceed the space provided below. Approx 400 words or 2800 characters. PROJECT REFERENCE DECLARAT IONS BY REFEREE ALL DECLARATIONS MUST BE COMPLETED. I agree to being contacted by the Churchill Trust as part of the selection process I state that all information in this reference is true and correct. I accept that the Churchill Trust has the right to reject an application or retract the award of a Churchill Fellowship on the basis of false or misleading information forming any part of a Churchill Fellowship application Referee's Signature Date: / / 20 APPLICATIONS CLOSE 28 APRIL 2017 Application Form 2017 Page 4 of 4
The Winston Churchill Memorial Trust The Winston Churchill Memorial Trust was established in Australia in 1965 shortly after the death of Sir Winston Churchill. The Trust is a not for profit educational institution governed by a Board of Directors who give their time voluntarily. The aim of The Winston Churchill Memorial Trust is to provide an opportunity for Australians to travel overseas to conduct research in their chosen field that is not readily available in Australia. No prescribed qualifications are required and the subject of the proposed project is limitless provided a benefit to Australia is evident. Merit of the proposed project is a key factor and a desire to share the research findings with the Australian community must be displayed. The value to the Australian community of the applicant s work and the extent to which it will be enhanced by an overseas research project are important criteria for the selection of Churchill Fellows. All Churchill Fellowship applicants need to demonstrate: past achievement in the field of their proposed project, and commitment to future contribution in the field of their proposed project. WHAT IS A PROJECT REFERENCE? Two references from different individuals are required to support each Churchill Fellowship application: one Professional Reference; and one Project Reference. The Project Reference must be typed or printed clearly on this Project Reference Form and must fit within the space provided. References provided on letterhead or other paper will not be accepted. This does not apply to the online application process. A Project Referee is expected to: be an Australian Citizen living in Australia be familiar with the field and topic of the proposed project have some knowledge of the applicant s standing in the field of their proposed project and have knowledge of the importance of the proposed project to the Australian community. A Project Reference should include the referee's knowledge and opinion regarding: the merit of the proposed project why the proposed project is necessary whether an opportunity exists in Australia for the completion of the proposed project and how you think both the applicant and the Australian community would benefit from the proposed project being completed. INFORMATION FOR REFEREES INFORMATION FOR APPLICANTS If the applicant has not already provided a copy of their application request one to assist you with the completion of your reference. You may paste a typed reference onto the form if it fits within the space provided. If you do so please sign your name in pen on the pasted sheet as verification, then sign your name again at the bottom of the form. If you are unable to complete a reference please contact the applicant promptly so that they may identify another referee. Return your reference to the applicant in plenty of time for them to meet the closing date of 16 February 2015. Your reference cannot be submitted individually. If you have any queries that the applicant is unable to assist you with please call the National Offce of the Trust on 1800 777 231 or 02 6247 8333. Ensure that you have completed the Applicant's Details at the top of the Project Reference Form. Send this form and a copy of your application to your Project Referee as early as possible. It is your responsibility to ensure that the reference is completed correctly and returned to you for submission with your application before the closing date. Applications received without one Professional Reference AND one Project Reference will not be accepted. To expedite the return of references to you, consider including a self-addressed, stamped envelope with each Referee Form for your referee to use when returning the completed reference. APPLICATIONS CLOSE 28 APRIL 2017