5770-2 Fellowship Application

Form Approved OMB Control No. 2030-0020
U.S. ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

“No fellowship may be awarded unless
a completed application form has been
received (40 CFR 46.120).”

FELLOWSHIP APPLICATION
TO BE COMPLETED BY EPA ONLY

(Read Instructions before completing)
DATE RECEIVED

FELLOWSHIP NUMBER

1. TYPE OF FELLOWSHIP REQUESTED (Check appropriate boxes)
† AGENCY † SPECIAL † FULL-TIME † PART-TIME
† AIR POLLUTION CONTROL
† WATER POLLUTION CONTROL
† DRINKING WATER SUPPLY † OTHER

2a. APPROXIMATE BEGINNING DATE ___________________________

3. NAME (Last, first, middle, maiden)

4. SOCIAL SECURITY NO.

6. Marital Status

7. Date of birth (Month, Day, Year)

b. WILL YOU ACCEPT A LATER DATE? † Yes

† No

IF YES, INDICATE DATE:__________________________________
5. SEX
† MALE

† FEMALE

8. BIRTHPLACE (City and state, if foreign born, city and country)

9. U.S. CITIZEN OR U.S. NON-CITIZEN NATIONAL † YES † NO IF “NO”, VERIFICATION FROM THE IMMIGRATION AND
NATURALIZATION SERVICE MUST BE SUBMITTED TO THE DIRECTOR, GRANTS ADMINISTRATION DIVISION, THAT YOU WERE
LAWFULLY ADMITTED TO THE U.S. FOR PERMANENT RESIDENCE.
10a. PRESENT MAILING ADDRESS (Street, City, State and Zip Code)

b. TELEPHONE (Include area code and extension)
BUSINESS:
________________________________________
HOME:
________________________________________

12.

b. TELEPHONE (Include area code and extension)
BUSINESS:
________________________________________
HOME:
________________________________________

EDUCATION

NAME AND LOCATION OF EDUCATIONAL
INSTITUTION ATTENDED SUBSEQUENT TO HIGH
SCHOOL (most recent)

13.

11a. PERMANENT MAILING ADDRESS (Street, City, State and Zip Code)

MAJOR FIELD OF STUDY

FROM
MO

YR

TO
MO

DEGREE(S) OBTAINED
YR

EMPLOYMENT

NAME AND LOCATION OF EMPLOYERS (including
Military Service, Internship, and Residencies, Most recent.)

OCCUPATION

FROM
MO

14.

YR

SALARY

TO
MO

YR

SPONSORSHIP

a. SPONSOR AT INSTITUTION (Name, title, and mailing address)

b. SPONSORING INSTITUTION (School, Department, Street, City, State and Zip
Code)

TELEPHONE (Include area code and extension)

C. NAME AND ADDRESS OF INSTITUTION WHERE TRAINING WILL TAKE PLACE (If different from 14b)

EPA Form 5770-2. Replaces EPA Form 5770-2A which is obsolete.

PAGE 1 OF 4

NAME (Last, first, middle, maiden)

FELLOWSHIP NO. (Leave Blank)

16. LIST NAMES OF 3 INDIVIDUALS (Other than your sponsor) YOU HAVE REQUESTED TO SUBMIT QUALIFICATIONS INQUIRY FORMS
NAME

TITLE

ADDRESS (Include Zip Code)

(a)

(b)

(c)

16. APPLICANT’S STATEMENT OF OBJECTIVES (See instruction sheet)

CERTIFICATION

I certify that the foregoing statement are true and complete to the best of my knowledge and belief, and understand
that any willfully false statement is sufficient cause for rejection of this application or, if a fellowship has been awarded, for
the termination of the fellowship.
I further agree that if a fellowship is awarded on the basis of this application or any revision or amendment thereof, I
will comply with all applicable statutory provisions and with the applicable terms, conditions, and procedures of the U.S.
Environmental Protection Agency grant regulations (40 CFR Chapter I, Subchapter B) and of the fellowship agreement.
SIGNATURE OF APPLICANT
EPA Form 5770-2. Replaces EPA Form 5770-2A which is obsolete.

DATE
PAGE 2 OF 4

PRIVACY ACT NOTICE FOR FELLOWSHIP APPLICATION
GENERAL. This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals seeking fellowships
from the U.S. Environmental Protection Agency.
AUTHORITY 40 C.F.R. 46-120
PURPOSED AND USES. Individuals seeking fellowships from the U.S. Environmental Protection Agency are required to use this form in applying for
such fellowships. Completed applications are submitted to the administering office of the U.S. Environmental Protection Agency. The information
provided on this form will be furnished to EPA personnel authorized to administer the program and to make evaluative determinations on the award of
Agency fellowships.
EFFECTS OF NONDISCLOSURE. Disclosure of the Information is voluntary; however, applicants who fail to complete the application will not be
eligible for fconsideration.
INSTRUCTIONS FOR EPA FORM 5770-2, FELLOWSHIP APPLICATION
THESE INSTRUCTIONS SHOULD BE READ AND FOLLOWED
CAREFULLY. AN APPLICATION WILL BE CONSIDERED
COMPLETE ONLY AFTER ALL THE INFORMATION, INCLUDING
ANY ADDITIONAL INFORMATION, HAS BEEN RECEIVED. FINAL
RECOMMENDATION OF AN APPLICATION WILL BE DELAYED
UNTIL THE APPLICATION IS COMPLETE.
The Application Kit consists of:
1. EPA Form 5770-2, Fellowship Application
2. EPA Form 5770-3, Fellowship Facilities and Commitment
Statement
3. EPA Form 5770-4, Fellowship Applicant Qualifications Inquiry
(3 sets in duplicate)
4. EPA Form 5770-5, Agency Fellowship Certification
5. EPA Form 5700-8, Grant Application/Proposal Receipt
6. Excerpt from Federal Register (40 CFR Part 46)
7. Two self-addressed envelopes (postage to be added)
8. Three envelopes for applicant qualifications inquiry
9. Address label
All items on the application should be answered unless otherwise
indicated in the instructions. If the answer is “no”, “none”, not
applicable”, etc., state so the fellow’s name should be typed in the
appropriated block one each page.
If the space provided in the application is insufficient for any particular
item, plain white bond paper may be used. Items continued on
supplemental pages must be numbered to correspond to the appropriate
item on the application form. Margins should be at least one-half inch on
the sides and one inch at the top and bottom. Forms and diagrams should
be drawn in heavy black lines. Do not staple. The application’s name
must be typed at the top of all supplemental pages.
Mailing. The completed application material including transcripts
should be forwarded by first-class mail to:
U.S. Environmental Protection Agency
Grants Administration Division (PM-216)
Washington, D.C. 20460
A self-addressed mailing label is enclosed for use in mail the application:
postage must be paid by applicant.
The EPA Form 5770-2, Fellowship Facilities and Commitment
Statement, which is completed by officials at the sponsoring institution
should arrive at the EPA not later than 10 calendar days after the
application is submitted.
The EPA Form 5770-8, Grant Application/Proposal Receipt,
Individuals desiring EPA notification that their application has been
received should not the postage requirement on the acknowledgment
postcard. Insert type of fellowship (Agency/Special) on card in lieu of
“Title of Proposed Project”. Be sure to give your name and address on
both the upper and lower half of the card.
EPA Form 5770-2. Replaces EPA Form 5770-2A which is obsolete.

Status of Materials Submitted. The Fellowship Application and related
documents such as transcripts become the property of EPA and cannot be
returned.
Item (s)
1. Agency fellowships are awarded to present or prospective
employees of a regional, State or local environmental pollution control or
regulatory agency to provide training for and upgrading of personnel
in the areas of pollution abatement and control. Applicants for this
type of fellowship must also complete the EPA Form 5770-5,
Agency Fellowship Certification, enclosed with this application kit.
Special fellowships are awarded to individuals for education and
training in pollution control science, engineering and technology and
in specialty areas which are supportive of pollution abatement and
control efforts.
Full-time is defined as a minimum of 12 semester or quarter hours
for credit or an academic workload otherwise defined by the
institution as a full-time curriculum.
Part-time is defined as being duly enrolled in an educational
program with at least three (3) credit hours per academic term.
2. This date should indicate the date that applicant desires to begin his
fellowship.
3 THRU 5

Self-explanatory.

6. SINGLE: (Includes widowed, separated, or divorced) or married.
7 AND 8

Self-explanatory.

9. At the time of application a noncitizen must have been lawfully
admitted to the United States for permanent residence. No proof of
citizenship is required if you are a citizen or noncitizen national of
the United States.
10. Indicate the address at which you may be reached at any time prior
to the beginning date of the requested fellowship. Future changes
should be reported promptly.
11. If the information given in Item 10 is not your permanent address,
state the address and telephone number through which you can
always be contacted. Any future changes should be reported
promptly.
12. List most recent training first and continue in descending order. If
you are currently working toward a degree, state the date you expect
to obtain it.

PAGE 3 OF 4

Item(s)

Item(s)
All applicants need to submit transcripts for that portion of their
undergraduate or graduate course work completed within the past 10
years. Registrar’s offices should be requested to send official
transcripts of grades to:

15.

U.S. Environmental Protection Agency
Grants Administration Division (PM-216)
Grants Operations Branch
Washington, D.C. 20460
13.

14a.

List most recent employment first and continue in descending order.
Account for all time, including time unemployed, subsequent to
completion of college. State under occupation the actual work
performed, or your position title. If not presently employed, state so
under “most recent.”

Reference reports should be requested only from individuals who
will be able to submit them on your behalf in time to be utilized by
EPA. Bare in mind any factor (e.g. illness or extended vacation,
etc.) which might cause an inordinate delay in the response.

Refers to the individual(s) under whom applicant will obtain
training or who will be responsible for its direction. Telephone
number must be given.
16.

14b. Refers to the institution(s) (whether academic or not) at which your
training will be obtained. State the particular, school, If any, from
which you will receive your degree and/or with which you will be
associated.
14c. Complete only if different from Item 14b. This applies to an
individual who will be training in an Institution or location other
than at the which his sponsor works.
If there are any unusual circumstances involved in your training
situation or if you are seeking a degree from an institution other than
the one in which the training will take place, give a detailed
description under Item 16.
EPA Form 5770-2. Replaces EPA Form 5770-2A which is obsolete.

It is most important that your references be carefully selected.
Graduate school references are preferred over those from
undergraduate schools. However, students enrolled in a graduate
degree program may use undergraduate references. List scientists or
faculty members (other than your sponsor), include, if applicable
your M.S. and Ph.D. thesis advisors whose knowledge of you and
your work permits them to give meaningful answers to the questions
asked. Your sponsor should provide this type of information on the
EPA Form 5770-3, Fellowship Facilities and Commitment
Statement. Where possible, you should select a respondent who is
not in the department where you are now studying but is
knowledgeable as to your qualifications. Also, if applicable, have
your immediate supervisor submit one of these forms.

THIS ITEM WILL BE OF PARAMOUNT IMPORTANCE IN
EVALUATING YOUR REQUEST FOR A FELLOWSHIP, YOUR
ANSWER, THEREFORE, SHOULD BE WELL THOUGHT OUT
AND EXPRESSED IN A CLEAR AND DETAILED BUT
CONCISE MANNER. State your reasons for desiring academic
training in environmental subjects. Include a statement of your
career objectives, your plans for specialization within the
environmental field and your exceptions of the contribution which
your fellowship training can make to your personal development and
career advancement. Discus your past experience and education and
its relationship to your proposed study. Indicate any features of

your
past academic record or work experience which you feel may need
explanation. Include information of any nature which your feel
would be helpful in evaluating your application.
PAGE 4 OF 4

Paperwork Reduction Act Burden Statement
The public reporting and record keeping burden for this collection
of information is estimated to average 3 hours per response. Send
comments on the Agency’s need for this information, the accuracy
of the provided burden estimate, 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.

EPA Form 5770-2