5770-05 Agency Fellowship Certification

U.S. ENVIRONMENTAL PROTECTION AGENCY
AGENCY FELLOWSHIP CERTIFICATION

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

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 0.5 hours
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: This form is used only by those applicants who are either present or prospective employees of a regional, State or local environmental pollution control
or regulatory agency (see Item 1 of EPA Form 5770-2, Instructions for Fellowship Application.) Complete the first two items and submit form to your supervisor for
completion (if you are presently employed by a regulatory agency defined in Item 1 of EPA Form 5770-2), or to the individual with whom you have discussed future
employment upon completion of proposed training. The supervisor (or other appropriate individual) should be requested to forward the completed form in the enclosed selfaddressed envelope. Applicant must affix necessary postage.

APPLICANT=S NAME

ADDRESS

SECTION A: COMPLETE THIS SECTION IF APPLICANT IS A CURRENT EMPLOYEE
1. APPLICANT IS A PERMANENT EMPLOYEE OF THIS AGENCY:
IF YES, FULL OR PART TIME______________________________________________
IF NO, STATE EMPLOYEE STATUS ________________________________________
2. DOES THE AGENCY HAVE AUTHORITY TO GRANT ADMINISTRATIVE LEAVE FOR TRAINING?
3. WILL YOU GRANT ADMINISTRATIVE LEAVE FOR THIS EMPLOYEE?
4. WILL YOU PROVIDE ANY FINANCIAL ASSISTANCE TO EMPLOYEE WHILE IN TRAINING?
IF YES, IDENTIFY TYPE AND AMOUNT OF ASSISTANCE ____________________________________________________
5. HAS EMPLOYEE ENTERED INTO A FORMAL AGREEMENT TO RETURN TO THIS AGENCY UPON COMPLETION OF
TRAINING?
6. EMPLOYEE=S SALARY IS: $_______________________________________________
7. WHAT POSITION DO YOU PROJECT FOR THIS EMPLOYEE UPON COMPLETION OF TRAINING?
8. IS THE TRAINING PROPOSED BY THE APPLICANT DIRECTLY RELATED TO THE WORK APPLICANT DOES OR WILL
DO FOR THE AGENCY?
SECTION B - COMPLETE THIS SECTION IF APPLICANT IS A POTENTIAL EMPLOYEE
SUBJECT TO FUNDING AND POSITION AVAILABILITY, UPON COMPLETION OF TRAINING WE WOULD CONSIDER THIS
INDIVIDUAL FOR EMPLOYMENT:
IF YES, INDICATE POTENTIAL POSITION:
WE RECOMMEND THAT THE FELLOWSHIP BE AWARDED.
REMARKS

SIGNATURE OF AGENCY DIRECTOR OR DESIGNEE

DATE

NAME OF REGIONAL, STATE OR LOCAL ENVIRONMENTAL POLLUTION CONTROL OR REGULATING AGENCY

TELEPHONE (Include Area Code)

ADDRESS

EPA Form 5770-5 (Rev. 6/2014)

Previous edition is obsolete

YES

NO