5770-4 Fellowship Applicant Qualifications Inquiry

OMB Control No: 2030-0020
Form Approved
OMB No. 2030-0020

U.S. ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON D.C. 20460
FELLOWSHIP APPLICANT QUALIFICATIONS INQUIRY
(Privileged Communications – Read reverse side)

INSTRUCTION
Applicant completes the first three Items and fords two copies to each of the persons listed in Item 15 of the EPA Form 5770-2, Fellowship Application.
Please use as respondents those individuals, other than your sponsor who can make a most meaningful comment about your qualifications. Respondents
should return this form to the applicant in the enclosed envelope.
Applicant must return the unopened envelope with the applicant to EPA.
1. Applicant’s Names

2. Type of Fellowship Requested

3. Sponsoring Institution

NOTE TO RESPONDENTS: The above named applicant has selected you as a reference relative to his request for an EPA fellowship. Your cooperation
in completing and returning this inquiry to the applicant would be appreciated.
4. DESCRIBE ANY QUALIFICATIONS YOU CONSIDER OF SPECIAL SIGNIFICANCE IN JUDGING THE APPLICANT’S FITNESS FOR A
CAREER IN POLLUTION CONTROL AND ABATEMENT. PLEASE INDICATE APPLICANT’S STRONG AND WEAK POINTS,
LEADERSHIP POTENTIAL AND CREATIVITY, ACADEMIC STRENGTH AND APTITUDE, WORK EXPERIENCE IN NON-ACADEMIC
ORGANIZATIONS, MOTIVATION FOR THE STUDY OF ENVIRONMENTAL SCIENCE, AND WILLINGNESS TO ATTACK COMPLEX
SITUATIONS.

5. SUMMARY EVALUATION:
HOW DO YOU RATE THE APPLICANT IN OVERALL ABILITY AND PROMISE IN COMPARISON WITH OTHER INDIVIDUALS OF
SIMILAR AGE, EXPERIENCE AND CAREER ORIENTATION?
† QUESTIONABLE WHETHER FELLOWSHIP SHOULD
BE AWARDED
† PERFORMANCE SHOULD BE UP TO THE AVERAGE
OF MOST GRADUATE STUDENTS
† EQUAL TO THE BEST OF INDIVIDUALS I KNOW

6. ASSOCIATED WITH APPLICANT FOR PERIOD:
FROM __________________ TO _________________
(Date)
(Date)
8. NAME AND TITLE OF RESPONDENT

10. SIGNATURE
EPA Form 5770-4 (Rev. 7-2009)

† QUALIFICATIONS MARGINAL BUT DESERVES
SUPPORT WITH LOW PRIORITY
† WILL PERFORM AT A SUPERIOR LEVEL
† NOT ABLE TO JUDGE

7. ASSOCIATED WITH APPLICANT IN FOLLOWING CAPACITY
† Teacher
† Advisor
† Supervisor
† Other (Specify):

9. ADDRESS

11. PHONE (Incl Area Code)
PREVIOUS EDITION IS OBSOLETE

12. DATE

PRIVACY ACT NOTICE FOR FELLOWSHIP
APPLICANT QUALIFICATIONS INQUIRY
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 and for individuals named as
respondents by the applicants.
AUTHORITY
40 C.F.R. 46.120
PURPOSES AND USES
Individuals seeking fellowships from the U.S. Environmental Protection Agency are required to secure three such
evaluative statements from respondents in completion of their application. Completed qualifications inquiries are to
be routed, unopened, through the applicant, 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 abilities of the applicants.
EFFECTS OF NONDISCLOSURE
Disclosure of the information sought is voluntary; however, applicants who fail to secure three completed evaluative
statements from respondents will not be eligible for EPA fellowship consideration.

FELLOWSHIP APPLICANT QUALIFICATIONS INQUIRY
Paperwork Reduction Act Notice
The public reporting and recordkeeping 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
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.
EPA Form 5770-4

(Rev. 7-2009)