5770-5 Agency Fellowship Certification

Approval expires 04/30/2012

U.S. ENVIRONMENTAL PROTECTION AGENCY
AGENCY FELLOWSHIP CERTIFICATION

Form Approved
OMB No.2030-0020

INSTRUCTIONS
This form is used only by those applicants who are either present or prospective employees of a regional, State or local environmental pollution control or
regulatory agency (see Item 1 of EPA Form 5770-2, Instructions for Fellowship Application.)
Complete the first two items and submit form to your supervisor for completion (if you are presently employed by a regulatory agency defined in Item 1
of EPA Form 5770-2), or to the individual with whom you have discussed future employment upon completion of proposed training. The supervisor (or
other appropriate individual) should be requested to forward the completed form in the enclosed self-addressed envelope. Applicant must affix necessary
postage.
APPLICANT=S NAME

ADDRESS

SECTION A: COMPLETE THIS SECTION IF APPLICANT IS A CURRENT EMPLOYEE

YES

NO

1. APPLICANT IS A PERMANENT EMPLOYEE OF THIS AGENCY:
IF YES, FULL OR PART TIME______________________________________________
IF NO, STATE EMPLOYEE STATUS ________________________________________
2. DOES THE AGENCY HAVE AUTHORITY TO GRANT ADMINISTRATIVE LEAVE FOR TRAINING?
3. WILL YOU GRANT ADMINISTRATIVE LEAVE FOR THIS EMPLOYEE?
4. WILL YOU PROVIDE ANY FINANCIAL ASSISTANCE TO EMPLOYEE WHILE IN TRAINING?
IF YES, IDENTIFY TYPE AND AMOUNT OF ASSISTANCE ____________________________________________________
5. HAS EMPLOYEE ENTERED INTO A FORMAL AGREEMENT TO RETURN TO THIS AGENCY UPON COMPLETION OF
TRAINING?
6. EMPLOYEE=S SALARY IS: $_______________________________________________
7. WHAT POSITION DO YOU PROJECT FOR THIS EMPLOYEE UPON COMPLETION OF TRAINING?
8. IS THE TRAINING PROPOSED BY THE APPLICANT DIRECTLY RELATED TO THE WORK APPLICANT DOES OR WILL
DO FOR THE AGENCY?
SECTION B - COMPLETE THIS SECTION IF APPLICANT IS A POTENTIAL EMPLOYEE
SUBJECT TO FUNDING AND POSITION AVAILABILITY, UPON COMPLETION OF TRAINING WE WOULD CONSIDER THIS
INDIVIDUAL FOR EMPLOYMENT:
IF YES, INDICATE POTENTIAL POSITION:
WE RECOMMEND THAT THE FELLOWSHIP BE AWARDED.
REMARKS

SIGNATURE OF AGENCY DIRECTOR OR DESIGNEE

DATE

NAME OF REGIONAL, STATE OR LOCAL ENVIRONMENTAL POLLUTION CONTROL OR REGULATING AGENCY

TELEPHONE (Include Area Code)

ADDRESS

EPA Form 5770-5 (Rev. 4/2012)

Previous edition is obsolete

The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes 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.