5770-3 Fellowship Facilities and Commitment Statement

U.S. ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460
FELLOWSHIP FACILITIES AND COMMITMENT STATEMENT

Form Approved.
OMB No. 2030-0020

INSTRUCTIONS
Applicant must complete Items 1 through 5 and then forward form to sponsor for his completion. The sponsor should complete the remainder of the form
and forward it in the enclosed self-addressed envelope. Applicant must affix necessary postage.
TO BE COMPLETED BY APPLICANT
1. Applicant’s Name

2. Department

3. School, College, or other Major Division

4. Institution

5. Type of Fellowship
† Agency

† Special

†Full Time

† Part Time

TO BE COMPLETED BY SPONSOR
This certifies that if a fellowship, as checked below, is awarded adequate facilities and supervision will be provided.
6. Applicant is a degree candidate
† Yes
† No

7. Candidate would normally be expected to complete Requirements for a _________________ degree by
(month and year): __________________

9. TITLE AND FULL-INSTITUTIONAL ADDRESS OF APPROPRIATE
FINANCIAL OFFICIAL TO WHOM CHECK SHOULD BE MAILED

8. ALLOWANCES
(See 40 CFR 46.110)

10. DOES PROPOSED
FELLOWSHIP INVOLVE
WORK WITH HUMAN
SUBJECTS OR
EXPERIMENTAL
ANIMALS?
† Yes

† No

Annual Tuition Costs
(Per credit hour, if applicable)
Fees Per Year
11. COMMENTS OF SPONSOR
a. Summarize your plans for applicant’s training including information which will assist in the evaluation of applicant. This proposed training and
facilities available to him. Include projection of course schedule providing course number, title, and credit hours to be taken. (Use continuation
pages if necessary).

b. If you are the program director of an EPA Training Grant, state what relationship this fellowship (If awarded will have to that program. (Use
continuation page if necessary).

12. Sponsor’s Signature

13. Typed Name

14. Area Code/Tel. No

15. Date

TO BE COMPLETED BY INDIVIDUAL AUTHORIZED TO COMMIT THE INSTITUTION
16. Signature
EPA Form 5770-3 (Rev 7-2009)

17. Typed Name

18. Area Code/Tel No.
PREVIOUS EDITION IS OBSOLETE

19. Date

FELLOWSHIP FACILITIES AND COMMITMENT STATEMENT
Paperwork Reduction Act Notice

This data is requested to comply with provisions mandated by: stature or regulations (40 CFR Part 30 and 31); OMB Circulars; or added by EPA to
ensure sound and effective assistance management. Accurate, complete data are required to obtain funding, while no pledge of confidentiality is provided.
The public reporting and recordkeeping burden for this collection of information is estimated to average 1 hour per response. Send comments on the
Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including
through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.