“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 DI RECTOR, GRANTS ADMINISTRATIO N 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 MA ILING 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 ATTENDE D 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 TRAINI NG 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 04/30/2012NAME (Last, first, middle, maiden) FELLOWSHIP NO. (Leave Blank)

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

NAME TITLE ADDRESS (Include Zip Code) (a)

(b)

(c)

16. APPLICANT’S STATEMENT OF OB JECTIVES (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 th is 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 c omply 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 4PRIVACY 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 s eeking fellowships from the U.S. Environmental Protection Agency.

AUTHORITY 40 C.F.R. 46-120 PURPOSED AND USES. Individuals seeking fell owships from the U.S. Environmental Protection Agency are required to use this form in applying for such fellowships. Completed applications are submitted to the ad ministering 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 determinat ions on the award of Agency fellowships.

EFFECTS OF NONDISCLOSURE. Disclosure of the Information is voluntary; however, applicants who fail to comple te 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 APPL ICATION 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 applicati on should be answered un less otherwise indicated

in the instructions. If the answer is “ no”, “none”, not applic able”, 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 numbere d to correspond to the appropriate item on the application form. Margins s hould 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, Fellowsh ip Facilities and Commitment

Statement , which is completed by official s at the sponsori ng institution,

should arrive at the EPA not late r than 10 calendar days after the application is submitted.

The EPA Form 5770-8, Grant Applica tion/Proposal Receipt, Individuals desiring EPA notification that their a pplication has been received should not the postage requirement on the ac knowledgment 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 e nvironmental pollution control or regulatory agency to provide traini ng 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 ot herwise defined by the institution as

a full-time curriculum.

Part-time is defined as being duly en rolled in an educational program with at least three (3) credit hours per academic term.

2. This date shoul d indicate the date that a pplicant desires to begin his fellowship.

3 THRU 5 Self-explanatory.

6. SINGLE: (Includes widowed, separa ted, 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 reque sted 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 numb er through which you can always be contacted. Any future cha nges should be reported promptly.

12. List most recent training first a nd 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 4Item(s)

All applicants need to submit transcripts for that portion of their undergraduate or graduate course wo rk 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, incl uding 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 appli cant will obtain training or who will be responsib le for its direction. Telephone number must be given.

14b. Refers to the institution(s) (whe ther academic or not) at which your training will be obtained. St ate 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 fr om 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 de gree 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, st udents 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 57 70-3, Fellowship Facilities and Commitment Statement. Where po ssible, 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 requ ested 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 inor dinate delay in the response.

16. THIS ITEM WILL BE OF PARAMOUNT IMPORTANCE IN EVALUATING YOUR REQUEST FOR A FELLOWSHIP, YOUR ANSWER, THEREFOR E, SHOULD BE WELL

THOUGHT OUT AND EXPRESSED IN A CLEAR AND

DETAILED BUT CONCISE MANNE R. State your reasons for desiring academic training in e nvironmental subj ects. Include a statement of your career objectives, your plans for specialization

within the environmental fiel d and your exceptions of the contribution which your fellowship training can make to your personal development and career a dvancement. Disc us your past experience and education and it s relationship to your proposed study. Indicate any features of yo ur past academic record or work experience which you feel ma y 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 coll ection 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 informati on. Send comments regarding this burden estimate or any other as pect of this collection if information, including suggestions for reducing the burden, to Chief, Information Policy Branch, PM-233, U.S. Environmental Protection Agency, 1200 Penns ylvania 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 

## )