“No fellowship may be awarded unless a completed application form has 

been received (40 CFR 46.120).”

TO BE COMPLETED BY EPA ONLY 

 U.S. ENVIRONMENTAL PROTECTION AGENCY 

 WASHINGTON, D.C. 20460 

 FELLOWSHIP APPLICATION (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: 

 b. WILL YOU ACCEPT A LATER DATE? Yes No 

 IF YES, INDICATE DATE: 

3. NAME (Last, first, middle, maiden) 4. SOCIAL SECURITY 

NO. 

5. SEX 

 MALE FEMALE 

6. Marital Status 7. Date of Birth (Month, Day, Year) 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: 

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

b. TELEPHONE (Include area code and extension) 

 BUSINESS: 

 HOME: 

12. EDUCATION 

FROM TO 

NAME AND LOCATION OF EDUCATIONAL 

INSTITUTION ATTENDED SUBSEQUENT TO 

HIGH SCHOOL (most recent) 

MAJOR FIELD OF STUDY 

MO YR MO YR 

DEGREE(S) OBTAINED 

 

13. EMPLOYMENT 

NAME AND LOCATION OF EMPLOYERS 

(including Military Service, Internship, and Residencies, 

Most recent.) 

OCCUPATION FROM TO SALARY 

 MO YR MO YR 

 

14. SPONSORSHIP 

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

TELEPHONE (Include area code and extension) 

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

Zip Code.) 

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

EPA Form 5770-2 (Rev 04/2012) Page 1 of 4 

 OMB Control No. 2030-0020 Approval expires 04/30/2012
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 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 (40 CFR Chapter I, Subchapter B) and of the fellowship agreement. 

SIGNATURE OF APPLICANT DATE 

EPA Form 5770-2 (04/2012) 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 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 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.

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 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. 

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.

EPA Form 5770-2 (04/2012) REPLACES EPA FORM 5770-2A WHICH IS OBSOLETE PAGE 3 OF 4
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: 

U.S. Environmental Protection Agency 

Grants Administration Division (PM-216) 

Grants Operations Branch 

Washington, D.C. 20460 

13. 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.” 

14a. Refers to the individual(s) under whom applicant will obtain 

training or who will be responsible for its direction. Telephone 

number must be given. 

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 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.

Item(s) 

15. 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. 

16. 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.

EPA Form 5770-2 (Rev 04/2012) Page 4 of 4 

Paperwork Reduction Act Notice 

Public reporting burden for the collection of this information is 

estimated to average 3 hours per response, including the time for 

reviewing instructions, searching existing data sources, gathering 

and maintaining the data needed; and completing and reviewing 

this collection of information. Send comments regarding this 

burden estimate or any other aspect of this collection if 

information, including suggestions for reducing the burden, to 

Chief, Information Policy Branch, PM-233, U.S. Environmental 

Protection Agency, 1200 Pennsylvania Avenue, N.W., 

Washington, DC 20460; and to the Paperwork Reduction Project, 

Office of Information and Regulatory Affairs, Office of 

Management and Budget, Washington, DC 2000503. 

EPA Form 5770-2 (Rev. 04/2012)