WPC  % dT+BO<֨tZ^[d \PX+7i!\2i՞eX q3H`yI\-D[X9*ry^ƛ;05Od Hz~ Ӟ9@XHY@wC'搡ݿ(`<_IBZH!aa^>Pಐi[UYDvt@O2: AԨPBF }e*4&`q0ѿ" @B!x2,0$Xs9bNĒܟO=_\RPquJK.Sծtº ɰ1fmJSe_ Q-(DW+PyqY@3Hwi#UN % 0: f a ^ # w/ 43 G V mX fo aq f a f a f a N B C HP LaserJet 2100 PCL6,,,,,,,,0(9 Z6Times New Roman RegularX($USUS.,XTABLE Al8s lM7.MBackup3|xUTTABLE BTABLE CTABLE DTABLE E ddd !USUS.,  _hhhh9XX*Zddd Xdd Xdd Xhp&hp&,dd ,6dd +  hh   U.S.ENVIRONMENTALPROTECTIONAGENCY d  AGENCYFELLOWSHIPCERTIFICATION |  FormApproved d OMBNo.20300020  |   INSTRUCTIONS X dThisformisusedonlybythoseapplicantswhoareeitherpresentorprospectiveemployeesofaregional,Stateorlocalenvironmentalpollutioncontrolor p regulatoryagency(seeItem1ofEPAForm57702,InstructionsforFellowshipApplication.)   Completethefirsttwoitemsandsubmitformtoyoursupervisorforcompletion(ifyouarepresentlyemployedbyaregulatoryagencydefinedinItem1 h ofEPAForm57702),ortotheindividualwithwhomyouhavediscussedfutureemploymentuponcompletionofproposedtraining.Thesupervisor(or   otherappropriateindividual)shouldberequestedtoforwardthecompletedformintheenclosedselfaddressedenvelope.Applicantmustaffixnecessary 0  postage.x    * Zdddd 6dd 6Zhp&hp&,dd ,dd +  X X APPLICANTSNAME  $   ADDRESS $    4  *Zd Pddd dd  Zhp&hp&,*!dd , dd ,dd +     SECTIONA:COMPLETETHISSECTIONIFAPPLICANTISACURRENTEMPLOYEE  x   YES  x   NO  x   1.APPLICANTISAPERMANENTEMPLOYEEOFTHISAGENCY:  T  ЀIFYES,FULLORPARTTIME______________________________________________ l  ЀIFNO,STATEEMPLOYEESTATUS________________________________________       T     T  2.DOESTHEAGENCYHAVEAUTHORITYTOGRANTADMINISTRATIVELEAVEFORTRAINING?  `   `   ` 3.WILLYOUGRANTADMINISTRATIVELEAVEFORTHISEMPLOYEE?  <   <   < 4.WILLYOUPROVIDEANYFINANCIALASSISTANCETOEMPLOYEEWHILEINTRAINING?  ЀIFYES,IDENTIFYTYPEANDAMOUNTOFASSISTANCE____________________________________________________  0    !   " 5.HASEMPLOYEEENTEREDINTOAFORMALAGREEMENTTORETURNTOTHISAGENCYUPONCOMPLETIONOF t# TRAINING?  $$   t%   t& 6.EMPLOYEESSALARYIS:$_______________________________________________ h h' /hh(h / $h)h $7.WHATPOSITIONDOYOUPROJECTFORTHISEMPLOYEEUPONCOMPLETIONOFTRAINING? *  h \+ /h,h / $-h $8.ISTHETRAININGPROPOSEDBYTHEAPPLICANTDIRECTLYRELATEDTOTHEWORKAPPLICANTDOESORWILL . DOFORTHEAGENCY?  P/   0   1  SECTIONBCOMPLETETHISSECTIONIFAPPLICANTISAPOTENTIALEMPLOYEE h 2 /h3h / $4h $SUBJECTTOFUNDINGANDPOSITIONAVAILABILITY,UPONCOMPLETIONOFTRAININGWEWOULDCONSIDERTHIS @5 INDIVIDUALFOREMPLOYMENT: 6 ЀIFYES,INDICATEPOTENTIALPOSITION: 87   P8   @9   @: WERECOMMENDTHATTHEFELLOWSHIPBEAWARDED.   ,;    ,<   ,= *Zd P d*!dd *! dd dd Zhp&hp&,%dd +  t! =t!  REMARKS !p >  X'%F *lZd Pd%dd %Zhp&hp&l,dd ,dd +  8(&F8(& SIGNATUREOFAGENCYDIRECTORORDESIGNEE (4'G   L)'H DATE (4'I   L)'J NAMEOFREGIONAL,STATEORLOCALENVIRONMENTALPOLLUTIONCONTROLORREGULATINGAGENCY *()K   +*M ADDRESS 4-+N   /.R TELEPHONE(IncludeAreaCode) 4-+S  /.W  EPAForm57705(Rev.7_Ԅ2009)_ԀPreviouseditionisobsolete