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New Researcher Award

Application Form

Applicant Details

TITLE _____________ SURNAME _____________________________________

GIVEN NAMES ____________________________________________________

POSTAL ADDRESS_________________________________________________

_________________________________________________________________

_________________________________________________________________

TELEPHONE (____)_________________ EMAIL _________________________

ASSTA MEMBERSHIP NUMBER (if applicable) __________________________

Please select and fill in appropriate information:

____ I am currently enrolled in postgraduate studies at an Australian
or New Zealand University.

DEGREE PROGRAMME (e.g. PhD full-time) ___________________________

DATE OF COMMENCEMENT  _________________________________

NAME OF ACADEMIC INSTITUTION _________________________________

_______________________________________________________________

DATE OF AWARD OF MY FIRST DEGREE ___________________________

...OR...

____ I am not enrolled in postgraduate study and I am within 2 years of the
awarding of my highest degree.

HIGHEST DEGREE (e.g. PhD) ______________________________________

DATE OF AWARDING OF MY HIGHEST DEGREE  ________________



Title of Paper submitted to SST Conference:

________________________________________________________________

________________________________________________________________

Authors on Paper (Applicant must be first author): _______________________

________________________________________________________________

Supervisor Declaration

I declare that the applicant satisfies all the eligibility requirements,
that the applicant was the main contributor to the work,
and that the information given on this application and all attachments provided
are true and accurate records and statements and I authorise ASSTA to verify any facts.
I understand that if any information is found to be false this application
and/or any subsequent awards may be cancelled.

Signature:______________________________________________ Date:________________________

Name: ____________________________________________________ Email:__________________________

Organisation: ________________________________________________

Role: (e.g PhD Supervisor) __________________________