5770-03 Fellowship Facilities and Commitment Statement

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

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

FELLOWSHIP FACILITIES AND COMMITMENT STATEMENT

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 1 hour
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.

INSTRUCTIONS: Applicant must complete Items 1 through 5 and then forward form to sponsor for his completion. The sponsor should
complete the remainder of the form and forward it in the enclosed self-addressed envelope. Applicant must affix necessary postage.
TO BE COMPLETED BY APPLICANT
1. Applicant’s Name
2. Department
3. School, College, or other Major Division

4. Institution

5. Type of Fellowship
Agency

Special
Full Time
Part Time
TO BE COMPLETED BY SPONSOR
This certifies that if a fellowship, as checked below, is awarded adequate facilities and supervision will be provided.
7. Candidate would normally be expected to complete Requirements for a _______________
6. Applicant is a degree candidate
Yes
No
degree by (month and year): _________________
9. TITLE AND FULL-INSTITUTIONAL ADDRESS OF APPROPRIATE
10. DOES PROPOSED
8. ALLOWANCES
FINANCIAL OFFICIAL TO WHOM CHECK SHOULD BE MAILED
FELLOWSHIP INVOLVE
(See 40 CFR 46.110)
WORK WITH HUMAN
SUBJECTS OR
EXPERIMENTAL
Annual Tuition Costs
ANIMALS?
(Per credit hour,
if applicable)
Yes
No
Fees Per Year
11. COMMENTS OF SPONSOR
a. Summarize your plans for applicant’s training including information which will assist in the evaluation of applicant. This proposed
training and facilities available to him. Include projection of course schedule providing course number, title, and credit hours to be
taken. (Use continuation pages if necessary).

b. If you are the program director of an EPA Training Grant, state what relationship this fellowship (If awarded will have to that
program. (Use continuation page if necessary).

12. Sponsor’s Signature

16. Signature

13. Typed Name

14. Area Code/Tel. No

15. Date

TO BE COMPLETED BY INDIVIDUAL AUTHORIZED TO COMMIT THE INSTITUTION
17. Typed Name
18. Area Code/Tel No.
19. Date

EPA Form 5770-3 (Rev 06/2014)

PREVIOUS EDITION IS OBSOLETE