5770-7 EPA Fellowship Activation Notice

OMB Control No. 2030-0020
UNITED STATES
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA FELLOWSHIP
ACTIVATION NOTICE
(Please complete by typewriter)

FELLOWSHIP NO.

DATE FELLOW WILL ENTER ON DUTY

NOTICE: All checks will be mailed to any address requested by fellow, except for tuition and fees which will be mailed to the sponsoring institution.
NAME OF FELLOW

NAME OF SPONSORING INSTITUTION

MAILING ADDRESS FOR STIPEND CHECK (Include ZIP Code)

MAILING ADDRESS FOR INSTITUTION CHECKS (Include ZIP Code)

FOR EPA USE ONLY
DATE OF AWARD NOTICE

OBJECT CLASSIFICATION CODE

ACCOUNT NO.

VENDOR CODE

APPROPRIATION NO
STIPEND

AWARD PERIOD

MONTHLY
$

FROM

TOTAL
$

SPECIAL INSTRUCTIONS

BOOK ALLOWANCE

$

TUITION AND FEES

$

THROUGH

LEVEL
† AGENCY

TOTAL AWARD

$

PREPARED BY

† SPECIAL
DATE

REMARKS

SIGNATURE OF FELLOW

AREA CODE

TELEPHONE NO

DATE

TELEPHONE NO

DATE

APPROVING SIGNATURE
SPONSOR OR DEPARTMENT HEAD (Please Indicate)

AREA CODE

INSTITUTION OFFICIAL RESPONSIBLE FOR PATENTS
EPA Form 5770-7 (6-73)

DATE
REPLACES FWPCA FORM - 188 WHICH IS OBSOLETE
AND PHS FORM 416-5 WHICH WILL NOT BE USED.

Paperwork Reduction Act Burden Statement
The public reporting and record keeping 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 estimate, 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 5770-7