5770-02 Fellowship Application

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020). Responses to this collection of information
are required to obtain an assistance agreement (40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2 CFR 1500, and 40
CFR Part 33 for awards made after December 26, 2014). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 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 to the Regulatory Support Division
Director, U.S. Environmental Protection Agency (2821T), 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.

U.S. ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

FELLOWSHIP APPLICATION

OMB Control No. 2030-0020
Approval expires MM/DD/YYYY

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

TO BE COMPLETED BY EPA ONLY
DATE RECEIVED
FELLOWSHIP NUMBER

(Read Instructions before completing)

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

WATER POLLUTION CONTROL

DRINKING WATER SUPPLY
3. NAME (Last, first, middle, maiden)
5 Marital Status

OTHER

2a. APPROXIMATE BEGINNING DATE:
b. WILL YOU ACCEPT A LATER DATE?

No

IF YES, INDICATE DATE:
4. SEX
MALE

Social Security Number
6. Date of Birth (Month, Day, Year)

Yes

FEMALE

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

8 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.
9a. PRESENT MAILING ADDRESS (Street, City, State and Zip Code)
10a. PERMANENT MAILING ADDRESS (Street, City, State and Zip Code)

b. TELEPHONE (Include area code and extension)
BUSINESS:
HOME:
11.
NAME AND LOCATION OF EDUCATIONAL
INSTITUTION ATTENDED SUBSEQUENT TO
HIGH SCHOOL (most recent)

12.
NAME AND LOCATION OF EMPLOYERS

(including Military Service, Internship, and Residencies,
Most recent.)

b. TELEPHONE (Include area code and extension)
BUSINESS:
HOME:
EDUCATION
MAJOR FIELD OF STUDY

FROM
MO
YR

MO

TO

YR

DEGREE(S) OBTAINED

EMPLOYMENT
OCCUPATION

13
a. SPONSOR AT INSTITUTION (Name, title and mailing address)

FROM
MO

YR

TO
MO

SALARY
YR

SPONSORSHIP
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 13b)

EPA Form 5770-2 (Rev 06/2015)

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NAME (Last, first, middle, maiden)

FELLOWSHIP NO. (Leave Blank)

14. 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)

15. 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 to 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 (2 CFR Parts 200 and 1500 and 40 CFR Chapter I, Subchapter B) and of the fellowship
agreement.
SIGNATURE OF APPLICANT
EPA Form 5770-2 (06/2015)

DATE
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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 EPA fellowship consideration.
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 to EPA according to the
instructions in the soliciations announcement.

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 4 Self-explanatory.
5. SINGLE: (Includes widowed, separated, or divorced) or married.
6 AND 7 Self-explanatory.
8. At the time of application a non-citizen must have been lawfully
admitted to the United States for permanent residence. No proof of
citizenship is required if you are a citizen or non-citizen national of the
United States.

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 (06/2015)

Status of Materials Submitted. The Fellowship Application and related
documents such as transcripts become the property of EPA and cannot be
returned.

9. 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.
10. If the information given in Item 9 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.
11. 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.

REPLACES EPA FORM 5770-2A WHICH IS OBSOLETE

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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 EPA according to he instructions in the
soliciation announcement.

12. 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.”
13a. Refers to the individual(s) under whom applicant will
obtain training or who will be responsible for its direction.
Telephone number must be given.
13b. 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.
13c. Complete only if different from Item 13b. This applies to
an individual who will be training in an Institution or location
other than at 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 15.

EPA Form 5770-2 (Rev 06/2015)

EPA Form 5770-2 (Rev. 06/2015)

Item(s)
14. 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.
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.
15. 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.
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