5770-7 EPA Fellowship Activation Notice

OMB Control No. 2030-0020
Approval expires 04/30/2012

UNITED STATES

EPA FELLOWSHIP

ENVIRONMENTAL PROTECTION AGENCY

ACTIVATION NOTICE

WASHINGTON, D.C. 20460

(Please type or print clearly)

FELLOWSHIP NO.
DATE FELLOW WILL ENTER ON DUTY

NOTICE:

EPA provides any payments to the sponsoring institution by check and provides any payments to the fellow either
electronically or by check as determined appropriate by EPA.
NAME OF FELLOW
NAME OF SPONSORING INSTITUTION
MAILING ADDRESS FOR PAYMENTS TO FELLOW (include ZIP code)

MAILING ADDRESS FOR PAYMENTS TO INSTITUTION (include
ZIP code)

FOR EPA USE ONLY
STIPEND

BOOK ALLOWANCE
TUITION & FEES
TOTAL AWARD

AWARD PERIOD

MONTHLY
$
TOTAL
$
$

FROM

$

LEVEL

THROUGH

SPECIAL INSTRUCTIONS

Agency
$

Special

PREPARED BY

DATE

REMARKS

SPECIALIST FOR PROJECT

AREA CODE

TELEPHONE NO.

SIGNATURE OF FELLOW

AREA CODE

TELEPHONE NO.

DATE

APPROVING SIGNATURES
AREA CODE

TELEPHONE NO.

DATE

SPONSOR OR DEPARTMENT HEAD (Please indicate)

EPA Form 5770-7 (6-73) Replaces FWPCA Form 188 which is obsolete, and PHS Form 416-5 which will not be used.

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.