Pacific Islands Region American Samoa Pelagic Longline L

FEDERAL FISHERIES APPLICATION FORM

For Office Use
Reviewed _______
Issued
_______
Transmit _______

OMB Control No.: 0648-0490
Expiration Date: 11/30/2009

PACIFIC ISLANDS REGION
NATIONAL MARINE FISHERIES SERVICE
1601 Kapiolani Blvd., Suite 1110
Honolulu, HI 96814-4700
Ph: (808) 944-2200

PLEASE PRINT RESPONSES
Version: 11/14/06

American Samoa Pelagic Longline Limited Access Program
Limited Entry Permit Application
Application Type (check only one type):

MAIL OR DELIVER (DO NOT FAX) COMPLETED FORM TO PACIFIC ISLANDS REGION

(Non-Refundable Application Processing Fee: $35.00, payable by check or money order to: Department of Commerce, NOAA. Charged for
all permit transactions unless otherwise noted below)

Additional Permit Issuance (Please indicate vessel size classification):
G A = 40’ or less
G B = 40.1’ – 50’
G C = 50.1’ – 70’

G D = 70’ or larger

Registration of vessel to initial permit or re-registration (applies to vessels which have been sold or sunk): [No application
processing fee charged for initial registration of vessel to initial permit]

Permit transfer (for permits registered to vessels of size Class A, B, C, and D, and Class B-1, C-1, and D-1 after three years)
G Family member
G Community organization
G Person with documented participation in the American Samoa
longline fishery (participation in vessel size Class A for Class A only)
NAME: ____________________________________________________
(Print first and last names, or name of community organization)

Family Relationship: _______________________
(if Family member is checked)

Permit Upgrade (Only for permit holders with Class A permits. Please indicate vessel class size to which you are upgrading):
G B-1 = 40.1’ – 50’
G C-1 = 50.1’ – 70’
G D-1 = 70’ or larger
[Retired permit number: ________________ ]
NOTE: This option expires 07/31/2009

VESSEL NAME: _______________________________________

VESSEL REGISTRATION NUMBER: ______________________

VESSEL OWNER: ____________________________________________
(First, Middle and Last Name, or Business Name)

SOCIAL SECURITY NUMBER: ____________________
(or TAXPAYER IDENTIFICATION NUMBER)

DATE OF BIRTH or INCORPORATON:
Use the Supplementary Information Sheet to list names and addresses of owners, partners or officers.
Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize collection of this information. This information is used to verify the identity of the applicant(s) and
to accurately retrieve confidential records related to federal commercial fishery permits. The primary purpose for requesting the SSN/TIN is for the collection and reporting on
any delinquent amounts arising out of such person’s relationship with the government pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134).Personal
information is confidential and protected under the Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.

BUSINESS MAIL ADDRESS: _________________________________________, ______________________, _______ __________
(Number, street, apt. no.)

BUSINESS PHONE: ______________________

(City/Village)

HOME PHONE: ____________________

(State)

(Zip)

CELL:

(Please include the area code for each number)

FAX:

EMAIL:

PERMIT APPLICANT:________________________________ ____________________________
(Print first, middle and last name)

DATE: _______________

(Signature)

Additional permit, permit renewal or upgrade, and vessel registration: Permit holder or applicant fills out “Permit Applicant” information above.
Permit transfers: The transferring permit holder completes Permit Transferor information below and signs, and the person receiving the permit fills completes and
signs the Permit Applicant information above.

PERMIT TRANSFEROR: ____________________________________
(Current owner)

(Print first and last name)

________________________________ DATE: ________
(Signature)

PERMIT NUMBER OF PERMIT WHICH IS BEING TRANSFERRED AWAY: __________________________
Please submit:
1) Payment for the non-refundable application processing fee, if required,
2) A copy of the vessel’s current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from the state/territorial
agency (undocumented vessel) to register a vessel to the permit,
3) Documentation of participation in the American Samoa longline fishery if applying for an Additional Permit, Permit Transfer, or Permit Upgrade, and
4) Signed letter from permit holder authorizing the permit applicant as their agent, if the agent is submitting the application.

OMB Control No.: 0648-0490
Expiration Date: 11/30/2009

American Samoa
Pelagic Longline Limited Access Program
Limited Entry Permit Application
SUPPLEMENTARY INFORMATION SHEET
Company/Corporation officers, owners, or partners:
NAME

MAILING ADDRESS

Check boxes are for office use only:

Previous ownership of longline vessel (prior to March 21, 2002): USCG COD _______ or AS Vsl Reg. _______

Vessel used to legally harvest Pacific pelagic management unit species with longline gear in the EEZ around American Samoa, and
those fish were landed in American Samoa, at some time on or prior to March 21, 2002

Currently holds Class A permit (for permit upgrades)

Current Protected Species workshop certification (for renewal)
Documented Evidence of Work on AS Longline Fishing Vessel:

.
.
.
.
.

.
.
.
.
.

PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 45 minutes for American Samoa longline limited access initial permit issuance, renewal, transfer or
upgrade. Send comments regarding this burden estimate and any other aspects of this collection of information, including suggestions for reducing this burden, to Regional
Administrator, NMFS Pacific Islands Region, 1601 Kapiolani Blvd., Suite 1110, Honolulu, Hawaii 96814-4700.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Western Pacific
Region. This will enable NMFS and the Western Pacific Fishery Management Council to (a) determine who would be affected by changes in management; (b) inform
license holders of changes in fishery regulations; and (c) determine whether the objectives of the fishery program are being achieved by monitoring entry and exit patterns
and other regulatory changes on person in the regulated fisheries as well as in related fisheries. Responses to the collection are required to obtain the benefit of a license for
the fishery involved (ref. 50 CFR 665.13). Data provided concerning the vessel and/or business of the respondents are handled as confidential under the Magnuson-Stevens
Fishery Conservation and Management Act (Sec. 402 (b)). Notwithstanding any other provision of the 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 Numbers.