Form 3-200-56 Incidental Take Permits Associated with a Habitat Conser

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		Expires <<Date>> OMB No. 1018-0094
Return to: U.S. Fish and Wildlife Service (USFWS) (see attached list)		Type of Activity: Native Endangered and Threatened Species – Incidental Take Permits Associated with a Habitat Conservation Plan (HCP)

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.

See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.

A.	Complete if applying as an individual
1.a. Last name			1.b. First name		1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)		3. Social Security No.	4. Occupation		5. Affiliation/ Doing business as (see instructions)
6.a. Telephone number		6.b. Alternate telephone number		6.c. Fax number	6.d. E-mail address

B.	Complete if applying on behalf of a business, corporation, public agency or institution
1.a. Name of business, agency, or institution				1.b. Doing business as (dba) 
2. Tax identification no.			3. Description of business, agency, or institution
4.a. Principal officer Last name			4.b. Principal officer First name				4.c. Principal officer Middle name/ initial		4.d. Suffix
5. Principal officer title 						6. Primary contact
7.a. Business telephone number		7.b. Alternate telephone number			7.c. Business fax number			7.d. Business e-mail address

C.		Applicant address All applicants complete address information
1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City	1.c. State			1.d. Zip code/Postal code:		1.e. County/Province		1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City	2.c. State		2.d. Zip code/Postal code:		2.e. County/Province		2.f. Country

D.	All applicants MUST complete
1.			Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount indicated on page 2. Federal, tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee – attach documentation of fee exempt status as outlined in instructions. (50 CFR 13.11(d))
2.		Do you currently have or have you ever had any Federal Fish and Wildlife permits? Yes  If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: _________________________________No 
3.		Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001. ________________________________________________________________________________________________________________________ Signature (in blue ink) of applicant/person responsible for permit (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)

Please continue to next page

** See page 14 for additional instructions on completing the above form. See page 15 for information on the Paperwork Reduction Act, Privacy Act, and Freedom of Information Act aspects of this application form.

Section E. ALL APPLICANTS COMPLETE SECTION E. Provide the information outlined in Section E. on the following pages. Be as complete and descriptive as possible. Please do not send pages that are over 8.5”X 11”, videotapes, or DVDs.

INCIDENTAL TAKE PERMITS ASSOCIATED WITH A

HABITAT CONSERVATION PLAN (HCP)

Have you obtained all required State, Federal or foreign government approval to conduct the activity you propose? Please be aware that there may be other requirements necessary to conduct this activity such as an import permit, collection permit, permission to work on Federal lands, Federal bird banding permit, Corps of Engineers permits, Environmental Protection Agency NPDES permits, State, county or local permits, etc.

 Yes. Provide a copy of the approval(s). List the State, Federal or foreign countries involved and type of document required. Include a copy of these documents with the application.

 I have applied. List the State, Federal or foreign countries involved and type of documents required. Provide the reasons why the permits have not been issued ___________________________________________________________.

 Not required. The proposed activity is not regulated.

Application Processing Fees

The application processing fee for a new Incidental Take permit, or to renew/re-issue an existing valid permit, is $100. If permit amendment is required at a time other than renewal/re-issuance, the processing fee is $50.

Check the appropriate box below and enclose check or money order payable to the U.S. Fish and Wildlife Service in the amount of

 $100 for a new permit

OR

 $100 to renew/re-issue my existing valid permit (with only minor changes such as updating my name and address) using my current application package on file.

OR

 $50 to make a substantive amendment (with major changes) to my existing valid permit [50 CFR 13.11(d)(2)].

If the information in your current application package in file has changed in a manner that triggers a major amendment or a change not otherwise specified in the permit, then you must apply for an amendment to your valid permit. For example, such major changes may include changes in location, activity, amount or type of take, or species to be covered by the permit. Please contact our Ecological Services Field Office located closest to your proposed activity for technical assistance in making this determination. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish & Wildlife Service’s office directory web page at http://www.fws.gov/offices/directory/listofficemap.html

Please check the type of amendment you are requesting --

 add species (specify) ________________________________________________________________________________

 add a geographic area  change in personnel

 other (specify) ____________________________________________________________________________________

If this application includes transfer or succession of a valid Incidental Take permit, please check the box below:

 Transfer or succession of a valid Incidental Take permit associated with a HCP using the current application package on file. No application fee is required.

Application Processing Time

To expedite a final decision on your application, you are urged to coordinate with us as soon as possible for guidance in assembling a complete application package. If you are renewing or amending a valid permit, your complete application package must be received at least 30 days prior to the expiration of the valid permit. This time period begins when we receive a complete permit application package and does not include any time required for requesting clarification or additional information about your application.

The time required to process an application for an Incidental Take permit will vary depending on the size, complexity, and impacts of the HCP involved. Procedurally, the most variable factor in application processing is the level of analysis required for the proposed HCP under the National Environmental Policy Act (e.g., whether an application requires preparation of an Environmental Impact Statement, Environmental Assessment, or whether a categorical exclusion applies), although other factors such as public controversy can also affect application processing times. The target processing timeline from when we receive a complete application package to our final decision on a permit application is: up to 3 months for low-effect HCPs, 4 to 6 months for HCPs with an Environmental Assessment, and up to 12 months for HCPs with a 90-day comment period and/or an Environmental Impact Statement. Although not mandated by law or regulation, these targets are adopted as U.S. Fish & Wildlife Service and National Marine Fisheries Service (NMFS/NOAA Fisheries) policy and all offices are expected to streamline their Incidental Take permit programs, and to meet these targets to the maximum extent practicable.

The information provided in your permit application will be used to evaluate your application for compliance with the Endangered Species Act, its implementing regulations (which may require a 30 day public comment period), and with U.S. Fish and Wildlife Service policy. Receipt and possession of a permit under the Endangered Species Act should be regarded as a privilege, as we must balance permit issuance with our duties to protect and recover listed species.

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for renewal, re-issuance or amendment.

If your activities may affect species under the authority of the National Marine Fisheries Service (NMFS/NOAA Fisheries), then you may need to obtain a separate permit from that agency. In addition we share jurisdiction with NMFS/NOAA Fisheries for sea turtles (e.g., we evaluate applications for permits to conduct activities impacting sea turtles on land, and NMFS/NOAA Fisheries evaluates applications for permits to conduct activities impacting sea turtles in the marine environment). To apply for a permit to conduct activities with sea turtles in the marine environment or other species under NMFS/NOAA Fisheries jurisdiction, please contact them via their permit web page at http://www.nmfs.noaa.gov/pr/permits/

We cannot issue an Incidental Take permit under Section 10(a)(2)(A)(i) of the Endangered Species Act unless you submit a conservation plan that specifies the impacts that are likely to result from the incidental take associated with your activity.

Our general permit regulations at 50 CFR 13.12(a)(9) allow us to collect such other information as we determine that is relevant to the processing of a permit application. Before you submit an application for an Incidental Take permit, we may require that you conduct biological surveys to determine which species and/or habitat would be impacted by the activities sought to be covered under the permit. Biological surveys provide information necessary to develop an adequate HCP, and to assess the biological impacts of the proposed activities. In addition, the information provided in a biological survey can reduce the applicant’s risk of take under Section 9 of the Endangered Species Act by ensuring that affected species and/or habitat are identified and appropriately covered under the permit.

You are required to obtain a Scientific Purposes, Enhancement of Propagation or Survival permit (commonly called a Recovery permit) from us before engaging in any biological survey activities that would take listed species. Contact our Ecological Services Field Office closest to the location of your activity to obtain technical assistance in determining the need for both a biological survey and a Recovery permit for your survey activity. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish & Wildlife Service’s office directory web page at http://www.fws.gov/offices/directory/listofficemap.html

If a biological survey is required, you will need to send us your complete Recovery permit application package at least 3 months prior to commencement of survey activities to facilitate processing of your Recovery permit application. The Recovery permit application is

designated as U.S. Fish & Wildlife Service form # 3-200-55 and can be found on our Endangered Species permit web page at http://www.fws.gov/forms/3-200-55.pdf.

We maintain a list of Recovery permittees (such as biological consultants) who have authorized the release of their contact information to third parties for conducting biological surveys on a contract basis. This list is provided to the public at the discretion of each U.S. Fish and Wildlife Service Regional Office as time and workload allow. Please be aware that this list does not represent an endorsement by us of any particular permittee.

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If you are not applying as an individual but as a business, corporation, institution, or non-Federal public agency (block B. on page 1 of the application), the person to whom the permit will be issued (e.g., the landowner, president, director, executive director, or executive officer) is legally responsible for implementing the permit. Although other people under the direct control of the permittee (e.g., employees, contractors, consultants) receive third party take authorization in their capacity as designees of the permittee, the individual named as the permittee ultimately is legally responsible for the permit and any activities carried out under the permit except as otherwise limited in the case of permits issued to State or local government entities under 50 CFR 13.25(e).

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If you wish to coordinate the processing of this permit application through an authorized agent, and to have that agent represent you as the primary contact with us, check the box below. Sign (in blue ink) and date the authorization statement, and provide contact information for your authorized agent.

G I hereby authorize the following person to act as an authorized agent on my behalf in the processing of this permit application and to furnish, upon request, supplemental information in support of this permit application.

_________________________ __________________

signature (in blue ink) date

_________________________

please print name legibly

Your Authorized Agent’s Contact Information (please print legibly)

Name: _______________________________

Address: _______________________________

_______________________________

City: ______________________ State: ___________ Zip Code: _________

Telephone: __________________________

Fax: __________________________

E-Mail: ___________________________

INCIDENTAL TAKE PERMIT APPLICATION INSTRUCTIONS

You have 4 options for providing the required information for an Incidental Take permit application. Choose only one option.

Incidental Take Permit Application: Option I. Renewal of a Valid Incidental Take Permit.

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for renewal.

Sign the following statement if you are applying to renew an existing valid Incidental Take permit. If you are proposing major changes to your Incidental Take permit, you must use Option II.

The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification language is required under 50 CFR 13.22(a).

I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife Service Incidental Take permit # ______________ are still current and correct and hereby request renewal of that permit.

_________________________ __________________

signature (in blue ink) date

_________________________

please print name legibly

* Please note: If you have signed the above statement, then your renewal request is complete. Please submit completed pages 1 through 5 of this application to our Regional Office (see attached list) covering the location of your proposed activity. Requests for renewals must be received no later than 30 days prior to permit expiration to ensure that your current permit remains in effect while we process your renewal request.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option II. Amended Incidental Take Permit (with major changes)

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for amendment.

Sign the following statement if you are proposing to amend a valid Incidental Take permit by making major changes. Such major changes may include changes in location, activity, amount or type of take, or species to be covered by the permit.

The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification language is required under 50 CFR 13.22(a).

I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife Service Incidental Take permit # ________________ are still current and correct, except for the changes listed below, and hereby request amendment of that permit.

_________________________ __________________

signature (in blue ink) date

__________________________

please print name legibly

Provide a brief description of the changes to your valid permit (answer the appropriate questions for these changes under Incidental Take Permit Application Option III. below). Please submit completed pages 1 through 6 of this application form (along with the changed information relative to Option III. below) to our Regional Office (see attached list) covering the location of your proposed activity.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option III. New Incidental Take Permit & Supplementary Information for Amendment of a Valid Permit (with major changes).

General permit regulations for the U.S. Fish & Wildlife Service can be found at 50 CFR 13. Regulations for an Incidental Take permit under the Endangered Species Act can be found at 50 CFR 17.22(b)(1) for endangered wildlife species and 50 CFR 17.32(b)(1) for threatened wildlife species.

Each landowner who wishes to be covered under a new or amended Incidental Take permit associated with an HCP must sign (in blue ink) and date the Incidental Take Permit Application Certification Notice at the end of this application, unless the landowner will be covered under this U.S. Fish & Wildlife Service Incidental Take permit via another vehicle, such as a certificate of inclusion (50 CFR 13.25(d)). Any change in the language of the Certification Notice must be reviewed by the Department of Interior, Office of the Solicitor and approved by the U.S. Fish & Wildlife Service. The same person who signs in box D. on page 1 of the application should sign the certification.

If the information in items A. - D. below is already provided in your final HCP (or Implementing Agreement, if applicable), then you do not have to provide it here. Instead, check the box below and use the spaces provided in items A. - D. to indicate the page numbers in your HCP or Implementing Agreement that provide the requested information.

 I am not providing the following information for items A. - D. as part of my Incidental Take permit application, because it is already provided in my final HCP or Implementing Agreement (copy attached or already submitted).

If the requested information in items A. - D. is not provided in your final HCP or final Implementing Agreement, or you are using Option II. to amend your existing valid Incidental Take permit, then attach separate pages for the missing information. In order to assist us in processing your request, please provide the item number (A. 1.a., etc.) of the required information before each of your responses. Thank you.

Please ensure that your final HCP and Implementing Agreement (if applicable) are attached if it has not been previously submitted.

If you have previously submitted a final draft HCP or Implementing Agreement, please indicate the document’s date.

Date of final draft HCP ____________

Date of final draft Implementing Agreement ______________

Applications for an Incidental Take permit associated with an HCP must provide the following specific information (relevant to the activity) under items A.- D. below in addition to the general information on page 1 of this application.

A. Identify species and activity:

1. For a new Incidental Take permit:

a. Provide the common and scientific names of the species being requested for coverage in the permit and their status (endangered (E), threatened (T), proposed endangered (PE), proposed threatened (PT), candidate for listing (C), or species likely to become a candidate (LC)).

b. Provide the number, age, and sex of such species to the extent known

c. Quantify the anticipated effects to their habitat.

d. Describe the land use or water management activity sought to be authorized for each species.

2. For an amended Incidental Take permit:

a. Identify the species to be added to your valid permit (provide both the scientific, to the most specific taxonomic level, and common names), as well as the species status (see 1.a.. above).

b. Provide the number, age and sex of such species to the extent known.

c. If any activities requested in this application differ from those authorized in your valid permit, then for each species state the currently authorized activity, the requested new activity, and how the new activity will impact each species.

d. Identify each activity associated with your project that would result in the incidental take of each species.

e. Quantify any anticipated effects to the habitat of each added species.

f. Identify species to be deleted from your valid permit and the reason(s) for the deletion.

Page(s) & source document : _________________________________________

B. Identify location of the proposed activity:

1. Provide the name of the State, county, and specific location of the proposed activity site(s). Include a formal legal description, section/township/range information, county tax parcel number, local address, or any other identifying property designation that will precisely place the location of the proposed activity site(s). Attach a location map and plat of the project site clearly depicting the project boundaries and the footprint and location of all portions of the property that would be affected by your proposed activities.

2. Provide the total number of acres covered by the HCP ____________

Is this the total acreage of the parcel? (circle one) yes no

3. Provide the approximate number of acres to be impacted _____________

4. Provide the approximate number of acres to be protected _____________

5. Provide a complete description, including timeframes, for implementation of proposed voluntary management activities to enhance, restore, or maintain habitat benefiting federally listed, proposed or candidate species, or other species likely to become candidates. Include schedules for implementing these activities.

Page(s) & source document:__________________________________________

C. Describe the proposed activities in the conservation plan:

You must submit a Habitat Conservation Plan. We strongly encourage you to ensure that your HCP is consistent with the Habitat Conservation Planning Handbook, subsequent Handbook addendums, and current policies to minimize delays in evaluating your application. The Handbook and other HCP information is available on the U.S. Fish & Wildlife Service’s Endangered Species web page at http://www.fws.gov/endangered/hcp/index.html

Provide a complete description of activity(ies) to be authorized or reference the applicable HCP or Implementing Agreement page numbers identifying the subject information.

The HCP must specify:

1. The impact that will likely result from the incidental taking. A discussion of the impact that will likely result from the incidental take should include quantification of any anticipated effects to the habitat of the species sought to be covered by the permit.

2. The steps that will be taken to minimize and mitigate such impacts, the funding that will be available to implement such steps, and the procedures to deal with unforeseen circumstances.

3. The steps that will be taken to monitor and report on such impacts, including a copy of the monitoring plan. We are authorized to require reports of activities conducted under a permit per the U.S. Fish & Wildlife Service’s general permit regulations at 50 CFR 13.45.

4. Alternative actions to such incidental taking that have been considered and the reasons why these alternatives are not proposed for use.

5. The biological goals(s) and objectives for the HCP.

6. The duration requested for the proposed permit.

Page(s) & source document : _________________________________________

D. Implementing Agreement

An Implementing Agreement

is is not (FWS Regional Office to circle one)

required as part of the permit application for a Habitat Conservation Plan.

This Implementing Agreement must be signed at finalization of the HCP. Are you willing to commit to an Implementing Agreement at finalization of the HCP?

 Yes, I am willing to commit to an Implementing Agreement. Please submit any unsigned, draft Implementing Agreement that you have prepared with our Field Office.

 No, I am not willing to commit to an Implementing Agreement.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option IV. Permit Transfer or Succession of a Permit

Complete the following if you are applying for transfer of a valid Incidental Take permit to you or obtaining rights of succession of a valid Incidental Take permit. In addition, you and the current permit holder may also need to sign an Assumption Agreement. Please contact our Ecological Services Field Office nearest your activity to determine whether you and the current permit holder need to execute an Assumption Agreement. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish & Wildlife Service’s office directory web page at http://www.fws.gov/offices/directory/listofficemap.html

Please indicate the name of the HCP to be transferred or succeeded and indicate the document’s date.

Name of HCP ____________________________________________________

Date of HCP _________________________

An Assumption Agreement

is is not (FWS Ecological Services Field Office to circle one)

required as part of the transfer or succession permit application for the HCP.

_________________________________________________________________________________________________________

Incidental Take Permit Application

Certification Notice

The same person who signs in box D. on page 1 of the application should sign (in blue ink) the following certification.

By submitting this application and receiving an Incidental Take permit pursuant to Section 10(a)(1)(B) of the Endangered Species Act, I

___________________________________________________________(print name(s)) attest that I/we own the lands indicated in this application, or have sufficient authority or rights over these lands to implement the measures of the Habitat Conservation Plan (and Implementing Agreement if applicable) covered by the Incidental Take permit. Further, upon receipt of the Incidental Take permit, I/we agree to conduct the activities as specified in the Habitat Conservation Plan (and Implementing Agreement if applicable) according to the terms and conditions of the Incidental Take permit and its supporting documents.

__________________________________ ______________

signature (in blue ink) date

__________________________________

please print name legibly

__________________________________ ______________

signature (in blue ink) date

__________________________________

please print name legibly

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The public reporting burden for completing this application for an Incidental Take permit is estimated to be 3 hours, including time for reviewing instructions, gathering and maintaining application data, and completing and reviewing the forms. Comments regarding the burden estimate or any other aspect of the reporting requirement(s) should be directed to the U.S. Fish & Wildlife Service Information Collection Clearance Officer, MS 222 ARLSQ, U.S. Fish and Wildlife Service, Washington, DC 20240.

An agency may not conduct and a person is not required to respond to a collection of information unless a currently valid OMB control number is displayed.

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USFWS Regional Contacts for Native Endangered & Threatened Species Permits

Pacific Region (Region 1): HI, ID, OR, WA, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and the Pacific Trust Territories

U.S. Fish and Wildlife Service

Endangered Species Permit Office

911 NE 11th Avenue

Portland, Oregon 97232-4181

Web: http://www.fws.gov/pacific/ecoservices/endangered/index.html

Phone: (503) 231-2071

email: [email protected]

Fax: (503) 231-6243

California & Nevada Operations Office (CNO): CA and NV

U.S. Fish and Wildlife Service

Endangered Species Permit Office

2800 Cottage Way, Suite W-2606

Sacramento, California 95825

Web: http://www.fws.gov/cno/es/recovery.html

Phone: (916) 414-6464

email: [email protected]

Fax: (916) 414-6486

Southwest Region (Region 2): AZ, NM, OK, and TX

U.S. Fish and Wildlife Service

Endangered Species Permit Office

500 Gold Avenue S.W. (street address)

P.O. Box 1306 (mailing address)

Albuquerque, New Mexico 87103-1306

Web: http://www.fws.gov/southwest/es/EndangeredSpecies/

Phone: (505) 248-6649

email: [email protected]

Fax: (505) 248-6788

Midwest Region (Region 3): IA, IL, IN, MI, MN, MO, OH, and WI

U.S. Fish and Wildlife Service

Endangered Species Permit Office

B.H. Whipple Federal Building

One Federal Drive

Fort Snelling, Minnesota 55111-4056

Web: http://www.fws.gov/southwest/es/EndangeredSpecies/

Phone: (612) 713-5343

email: [email protected]

Fax: (612) 713-5292

Southeast Region (Region 4): AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN, and U.S. Virgin Islands

U.S. Fish and Wildlife Service

Endangered Species Permit Office

1875 Century Blvd., Suite 200

Atlanta, Georgia 30345

Web: http://www.fws.gov/southeast/es/#

Phone: (404) 679-4176

email: [email protected]

Fax: (404) 679-7081

Northeast Region (Region 5): CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VA, VT, and WV

U.S. Fish and Wildlife Service

Endangered Species Permit Office

300 Westgate Center Drive

Hadley, MA 01035-9589

Web: http://www.fws.gov/northeast/endangered/

Phone: (413) 253-8628

email: [email protected]

Fax: (413) 253-8482

Mountain-Prairie Region (Region 6): CO, KS, MT, NE, ND, SD, UT, and WY

U.S. Fish and Wildlife Service

Endangered Species Permit Office

Denver Federal Center

P.O. Box 25486

Denver, Colorado 80225-0489

Web: http://www.fws.gov/mountain%2Dprairie/endspp/

Phone: (303) 236-7400

email: [email protected]

Fax: (303) 236-0027

Alaska Region (Region 7): AK

U.S. Fish and Wildlife Service

Endangered Species Permit Office

1011 E. Tudor Road

Anchorage, Alaska 99503-6199

Web: http://alaska.fws.gov/fisheries/endangered/index.htm

Phone: (907) 786-3323

email: [email protected]

Fax: (907) 786-3350

PERMIT APPLICATION FORM INSTRUCTIONS

The following instructions pertain to the standard permit form 3-200 that must be completed as an application for a U.S. Fish and Wildlife Service or CITES permit. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates will be referred to as a permit.

GENERAL INSTRUCTIONS:

• Complete all blocks/lines/questions in Sections A or B, and C and D. Complete all of Section E.

• An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate application form for the proposed activity.

• Print clearly or type in the information. Illegible applications may cause delays.

• Sign the application in blue ink. Faxes or copies of the original signature will not be accepted.

• Mail the original application to the address at the top of page one of the application or if applicable on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 60 days for your application to be processed. Some applications may take longer than 90 days to process. (50 CFR 13.11)

• Applications are processed in the order they are received.

• Additional forms and instructions are available from http://permits.fws.gov/ .

COMPLETE EITHER SECTION A OR SECTION B:

Section A. Complete if applying as an individual:

• Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the applicant. Fax and e-mail are not required if not available.

• If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be included with the application.

• Affiliation/ Doing business as (dba): business, agency, organizational, or institutional affiliation directly related to the activity requested in the application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division of Management Authority (DMA) will not accept doing business as affiliations for individuals.

Section B. Complete if applying as a business, corporation, public agency, or institution:

• Enter the complete name of the business, agency or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the applicant is engaged in. Provide contact phone number(s) of the business.

• Principal Officer is the person in charge of the listed business, corporation, public agency, or institution. The principal officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at the business, corporation, public agency, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted to the Division of Management Authority (DMA) a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs which use foreign addresses and are not required by DMA..

• Mailing address is address where communications from USFWS should be mailed if different than applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is required at the time of application; unless exempted under 50 CFR13.11(d)(3). The application processing fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit. Fees will not be refunded for applications that are approved, abandoned, or denied. We may return fees for withdrawn applications prior to any significant processing occurring.

• Documentation of fee exempt status is not required for Federal, tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Those applicants acting on behalf of such agencies must submit a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most current FWS or CITES permit or the number of the most recent permit if none are currently valid. If applying for re-issuance of a CITES permit, the original permit must be returned with this application.

Section D.3 CERTIFICATION:

• The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation must be included in the application) must sign and date the application in blue ink. This signature binds the applicant to the statement of certification. This means that you certify that you have read and understand the regulations that apply to the permit. You also certify that everything included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

Please continue to next page

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:

1. The gathering of information on fish and wildlife is authorized by:

(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.shtml.)

a. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;

b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;

c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;

d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;

e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;

f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;

g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/ , 50 CFR 23;

h. General Provisions, 50 CFR 10;

i. General Permit Procedures, 50 CFR 13; and

j. Wildlife Provisions (Import/export/transport), 50 CFR 14.

2. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. Response is not required unless a currently valid Office of Management and Budget (OMB) control number is displayed on form.

3. Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972 (16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4. Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)

a. Routine disclosure to subject matter experts, and Federal, tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records.

b. Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the decision on a permit application.

c. Routine disclosure to Federal, tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all applicable permitting requirements.

d. Routine disclosure to Captive‑bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive breeding of these species.

e. Routine disclosure to Federal, tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.

f. Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or administrative body, under certain circumstances.

g. Routine disclosure to the appropriate Federal, tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or regulated use.

h. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.

i. Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.

j. Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by the FWS.

5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application.

6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for an Incidental Take permit application is 3 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop 222, Arlington Square, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.

Freedom of Information Act – Notice

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].

Form 3-200-56 Rev. August 2007 Page Page 2 of 15