Emergency medical transfer form

Revised: May 16, 2006 OMB No. 0648-new

Expiration Date: xx/xx/xxxx

	APPLICATION FOR EMERGENCY MEDICAL TRANSFER (EMT) OF IFQ		U .S. Dept. of Commerce/NOAA National Marine Fisheries Service Restricted Access Management P.O. Box 21668 Juneau, AK 99802-1668 (800) 304-4846 toll free / 586-7202 in Juneau (907) 586-7354 fax
NOTE: A separate application must be submitted for each IFQ Emergency Medical Transfer. Emergency Medical Transfers will remain in effect only for the calendar year of the transfer.
BLOCK A
Does the Transferee (No Medical Condition) hold a Transfer Eligibility Certificate (TEC)? Yes [ ] No [ ] Does the Transferor (Medical Condition) qualify for a hired master exception under 50 CFR 679.42(i)(1)? Yes [ ] No [ ]
BLOCK B -- ATTACHMENTS
USE THIS LIST TO ENSURE YOUR APPLICATION IS COMPLETE. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. NOTE: FAXED APPLICATIONS ARE NOT ACCEPTABLE. PLEASE SUBMIT ORIGINALS.
Completed, signed, and notarized application .......................................................................................... Copy of permit or QS Certificate....……………………………………………………………………... Declaration from certified medical professional…………………………………………………………					[ ] [ ] [ ]
BLOCK C – TRANSFEROR INFORMATION (MEDICAL CONDITION)
1. Name:			2. NMFS Person ID:
3. Date of Birth:			4. SSN (required)* or Tax ID:
5. Permanent Business Mailing Address:			6. Temporary Business Mailing Address (see instructions):
7. Business Telephone No.:		8. Business Fax No.:		9. e-mail Address (if any):

*The Debt Collection Improvement Act, in Section 7701 of title 31, United States Code requires collection of this information from each person doing business with a federal agency. This information is used for purposes of collecting and reporting any delinquent amounts arising out of such person’s relationship with the government. This information is also used to verify the identity of the applicant(s) and to accurately retrieve confidential records related to federal commercial fishery permits issued under

50 CFR Part 679.

.

BLOCK D – TRANSFEREE (NO MEDICAL CONDITION)
1. Name:		2. NMFS Person ID:
3. Date of Birth:		4. SSN* (required) or Tax ID:
5. Permanent Business Mailing Address:		6. Temporary Business Mailing Address (see instructions):
7. Business Telephone No.:	8. Business Fax No.:		9. E-mail Address (if any)

*The Debt Collection Improvement Act, in Section 7701 of title 31, United States Code requires collection of this information from each person doing business with a federal agency. This information is used for purposes of collecting and reporting any delinquent amounts arising out of such person’s relationship with the government. This information is also used to verify the identity of the applicant(s) and to accurately retrieve confidential records related to federal commercial fishery permits issued under

50 CFR Part 679.

BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED
1. Halibut [ ] or Sablefish [ ]	2. IFQ Regulatory Area:		3. Number of Units:
4. Numbered To and From (Serial Numbers are shown on the QS Certificate):
5. Actual Number of IFQ Pounds:		6. Transferor (Seller) IFQ Permit Number:
7. Fishing Year: 20______

REQUIRED SUPPLEMENTAL INFORMATION

YOUR APPLICATION WILL NOT BE PROCESSED UNLESS YOU PROVIDE THE FOLLOWING INFORMATION

BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION

1. Give the price per pound (including leases) $ ____________________________/#IFQ (Price divided by IFQ pounds)

Including fees

2. What is the total amount being paid for the IFQ in this transaction, including all fees? _____________________________

BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION

1. What is the primary source of financing for this transfer (check one)?

Personal resources (cash) [ ] AK Com. Fish & Ag. Bank [ ] Received as a gift [ ]

Private bank/credit union [ ] Transferor/seller [ ] NMFS loan program [ ]

Alaska Dept. Of Commerce [ ] Processor/fishing company [ ] Other (explain) [ ]

2. How was the IFQ located (check all that apply)?

Relative [ ] Advertisement/public notice [ ] Broker [ ]

Personal friend [ ] Casual acquaintance [ ] Other (explain) [ ]

3. What is the Buyer's relationship to the IFQ Holder (check all that apply)?

No relationship [ ] Relative [ ] Business partner [ ] Other (explain) [ ]

Family member [ ] Friend [ ]

BLOCK H – MEDICAL DECLARATION (to be completed by licensed medical doctor, advanced nurse practitioner, or primary community health aid)
1. Name of Treating Medical Professional:	2. Business Telephone Number:
3. Permanent Business Mailing Address:	4. Type of Medical Professional: Licensed Medical Doctor [ ] Advanced Nurse Practitioner [ ] Primary Community Health Aide [ ]
5. Description of the medical condition affecting the applicant or applicant’s family member (attach documentation of the medical condition and a description of the care required):
I acknowledge the requirements for receiving an Emergency Medical Transfer and certify that, to the best of my knowledge and belief, the information presented here is true, correct, and complete. The medical condition described above would prevent the applicant from participating in the IFQ fishery or, in the case of a family member, require continuous care that would preclude the applicant’s participation in the IFQ fishery.
6. Signature of Treating Medical Professional:		7. Date:

NOTE: This application for transfer must be completed, signed, and notarized by both parties. Failure to have signatures properly notarized will result in delays in the processing of this application.

BLOCK I –CERTIFICATION OF TRANSFEROR (SELLER)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the information presented here is true, correct, and complete.
1. Signature of Transferor (Seller) or Authorized Agent:		2. Date:
3. Printed Name Transferor (Seller) or Authorized Agent Note: If agent, attach authorization:
4. Notary Public Signature: ATTEST	5. Affix Notary Stamp or Seal Here:
6. Commission Expires:

BLOCK J – CERTIFICATION OF TRANSFEREE (BUYER)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the information presented here is true, correct, and complete.
1. Signature Transferee (Buyer) or Authorized Agent:		2. Date:
3. Printed Name Transferee (Buyer) or Authorized Agent Note: If agent, attach authorization:
4. Notary Public Signature: ATTEST	5. Affix Notary Stamp or Seal Here:
5. Commission Expires:

Revised: May 15, 2006

INSTRUCTIONS: Application for Emergency Medical Transfer (EMT) of IFQ

The requirement of 50 CFR part 679.41(c) for an individual IFQ card holder to be aboard the vessel during fishing operations and to sign the IFQ landing report may be waived as described at 50 CFR part 679.41(d). An emergency medical transfer (EMT) may be approved if the applicant demonstrates that he or she is unable to participate in the IFQ fishery for which he or she holds IFQ:

● Because of a severe medical condition that precludes participation; or

● Because of a severe medical condition involving an immediate family member that requires the IFQ holder’s full time attendance.

Eligibility. To be eligible to receive an EMT, an individual halibut or sablefish QS holder:

Must possess one or more catcher vessel IFQ permits.

Must not qualify for a hired master exception.

Note: A Separate Application must be submitted for each Emergency Medical Transfer of IFQ.

The original application must be submitted — an application sent by facsimile will not be processed.

Please allow at least ten working days for your application to be processed. Items will be sent by first class mail, unless you provide alternate instructions and include a prepaid mailer with appropriate postage or corporate account number for express delivery.

If you need assistance in completing this application or need additional information, call Restricted Access Management at (800) 304-4846 (#2) or (907) 586-7202 (#2).

When completed, mail or deliver the application to

NMFS Alaska Region

Restricted Access Management

P.O. Box 21668

Juneau, AK 99802-1668

or

709 West 9th Street, Room 713

Note: It is important that all blocks are completed and all necessary documents are attached. Failure to answer any of the questions, provide attachments, or to have signatures notarized could result in delays in the processing of your application.

BLOCK A

Any person that received QS/IFQ as an Initial Issuee or that holds a Transfer Eligibility Certificate (TEC) is eligible to receive QS/IFQ by transfer. If you answer "No," the transferee (buyer) will need to contact RAM for instructions on eligibility procedures and a TEC application form.

Persons who qualify for a hired master exception under 50 CFR §679.42(i) are ineligible to receive an EMT. If you check “Yes,” the submitted EMT application will be denied.

BLOCK B

Use this list as a guide to make sure you have included all the necessary items in the mailing of your application. This will ensure timely processing of your transfer application. You must attach the completed Medical Declaration and a copy of the IFQ permit or QS certificate to be considered for an Emergency Medical Transfer.

BLOCKS C & D

TRANSFEROR (SELLER) AND TRANSFEREE (BUYER)

1. Name: Full name as it appears on QS Certificate and/or Transfer Eligibility Certificate (TEC).

2. NMFS Person ID: As found on QS Certificate or TEC.

3. Date of Birth: Birth date of the person.

4. SSN or Tax ID:

The Debt Collection Improvement Act, in Section 7701 of title 31, United States Code requires collection of this information from each person doing business with a federal agency. This information is used for purposes of collecting and reporting any delinquent amounts arising out of such person’s relationship with the government. This information is also used to verify the identity of the applicant(s) and to accurately retrieve confidential records related to federal commercial fishery permits issued under 50 CFR Part 679.

5. Permanent Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.

6. Temporary Business Mailing Address: Address you want the transfer documentation sent if some-where other than to the permanent address. Include street or P.O. Box number, city, state, and zip code.

9. Business Telephone and Fax Numbers (Include the area codes), and E-mail Address (if any).

BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED

1. Indicate whether halibut or Sablefish IFQ.

2. IFQ Regulatory Area:

3 Number of Units:

4. Numbered To and From (Serial Numbers are shown on the QS Certificate):

5. Actual Number of IFQ Pounds

5. Transferor (Seller) IFQ Permit Number

7. Indicate Fishing Year

BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION

1. The price per pound of IFQ must be entered for IFQs that are being transferred under an EMT. (To derive the number of dollars per unit of QS or pound of IFQ, divide the total amount paid, including fees, by the number of QS units or the number of IFQ pounds being transferred.)

2. The total amount entered should include any and all monies collected on behalf of the seller for the shares involved, including any fees that will be paid out to other parties for the expenses of brokering or assisting in the sale of these shares.

BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION

1. Indicate the primary source of financing for this transfer (check one).

2. Indicate how the IFQ was located (check all that apply).

3. Indicate Buyer's relationship to the IFQ Holder (check all that apply).

BLOCK H -- MEDICAL DECLARATION

(Completed by licensed medical doctor, advanced nurse practitioner,

or primary community health aide)

3. The medical professional who conducted the medical examination must print or type their name, business telephone number, and permanent business mailing address.

4. The medical professional who conducted the medical examination must check the box indicating

The medical category they fall within.

5. The medical professional conducting the medical examination must provide a concise description

of the medical condition affecting the applicant or the applicant’s family member. The medical

professional may attach the original medical report or additional information if necessary.

6. The medical professional who conducted the medical examination must sign and date the

declaration.

BLOCK I - CERTIFICATION OF TRANSFEROR

1. Sign and print your name and date the application. If completed by a representative, attach authorization..

2. A Notary Public must Attest, affix Notary Stamp, and provide date commission expires. The Notary Public cannot be the person(s) submitting this application.

BLOCK J - CERTIFICATION OF TRANSFEREE

1. Sign and print your name and date the application. If completed by a representative, attach authorization..

2. A Notary Public must Attest, affix Notary Stamp, and provide date commission expires. The Notary Public cannot be the person(s) submitting this application.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting for this collection of information is estimated to average 2 hours per response, including the time for reviewing the instructions, searching the existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Assistant Regional Administrator, Sustainable Fisheries Division, NOAA National Marine Fisheries Service, P.O. Box 21668, Juneau, AK 99802-1668.

ADDITIONAL INFORMATION

Before completing this form please note the following: 1) Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information, subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number; 2) This information is mandatory and is required to manage commercial fishing efforts under 50 CFR part 679 and under section 402(a) of the Magnuson-Stevens Act (16 U.S.C. 1801, et seq.); 3) Responses to this information request are confidential under section 104(b) of the Magnuson-Stevens Act). They are also confidential under NOAA Administrative Order 216-100, which sets forth procedures to protect confidentiality of fishery statistics.

Application for Emergency Medical Transfer of IFQ

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