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pdfOMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
Revised: 05/21/2007
Application for Amendment 80
Cooperative and CQ Permit Issuance
U.S. Dept. of Commerce/
NOAA National Marine Fisheries Service
Restricted Access Management
P.O. Box 21668
Juneau, AK 99802-1668
Fax: 907-586-7354
Telephone: 800-304-4846 toll free / 586-7202 in Juneau
A CQ permit is issued annually to an Amendment 80 cooperative that submits a complete and timely
application for CQ and each member of the Amendment 80 cooperative holding Amendment 80 QS has
submitted an Economic Data Report as described under § 679.94 that is subsequently approved by the
Regional Administrator.
This application must be submitted annually and received by NMFS no later than 1700 hours A.l.t. on
November 1 of the year prior to the year for which the applicant wishes to participate in an Amendment
80 fishery, or if sent by U.S. mail, the application must be postmarked by that time.
BLOCK A – AMENDMENT 80 COOPERATIVE IDENTIFICATION
1. Cooperative's legal name
2. Type of business entity under which the
Amendment 80 Cooperative is organized
3. State in which the Amendment 80
Cooperative is legally registered as a business
entity
4. Permanent business address
5. Business telephone number
6. Business fax number
7. E-mail address (if available)
8. Printed name of Amendment 80 Cooperative’s designated representative
Amendment 80 Cooperative CQ Permit
Page 1 of 8
OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
BLOCK B – MEMBERS OF THE AMENDMENT 80 COOPERATIVE
1. Full name
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
1. Full name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
1. Full name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 Cooperative CQ Permit
Page 2 of 8
OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
1. Full name
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
1. Full name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
1. Full name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 QS Permit Holder and Ownership Documentation
2. NMFS Person ID
3. Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the Amendment 80 QS
permit(s) assigned to the Amendment 80 cooperative and the percentage ownership each person and individual holds
in the Amendment 80 QS permit(s).
Name
% Ownership in Amendment 80 QS Permit(s)
Amendment 80 Cooperative CQ Permit
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OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
BLOCK C – IDENTIFICATION OF AMENDMENT 80
COOPERATIVE MEMBER VESSELS AND AMENDMENT 80 LLP LICENSES
ADF&G No./USCG
Amendment 80 LLP license
Vessel Name
number
documentation number
Amendment 80 Cooperative CQ Permit
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OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
BLOCK D -- IDENTIFICATION OF VESSELS ON WHICH THE CQ ISSUED TO THE
AMENDMENT 80 COOPERATIVE WILL BE USED
Vessel name
ADF&G No./USCG
documentation number
BLOCK E -- EDR SUBMISSION
Has each member of the Amendment 80 cooperative submitted a timely and complete EDR for each
Amendment 80 QS permit held by that person as required under § 679.94?
[__] YES
[__] NO
BLOCK F – CERTIFICATION OF COOPERATIVE AUTHORIZED REPRESENTATIVE
The Cooperative Authorized Representative must sign and date the application certifying that all
information is true, correct, and complete to the best of his/her knowledge and belief. Attach explicit
authorization to complete the application on behalf of the members of the cooperative.
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 Cooperative Authorized Representative
3. Printed Name of Cooperative Authorized Representative
Amendment 80 Cooperative CQ Permit
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2. Date Signed
OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
Application for Amendment 80
Cooperative and CQ Permit Issuance
This completed application must be received by NMFS no later than 1700 hours A.l.t. on November 1 of
the year prior to the year for which the applicant wishes to participate in a Amendment 80 fishery, or if
sent by U.S. mail, the application must be postmarked by that time.
A CQ permit authorizes an Amendment 80 cooperative to participate in the Amendment 80 Program. A
CQ permit is issued annually to an Amendment 80 cooperative if that Amendment 80 cooperative has:
•
submitted a complete and timely application for CQ;
•
each member of the Amendment 80 cooperative holding Amendment 80 QS has submitted an
Economic Data Report as described under § 679.94 that is subsequently approved by the
Regional Administrator.
●
An Amendment 80 CQ Permit is valid under the following circumstances:
Until the end of the year for which the Amendment 80 limited access fishery permit is issued;
Until the Amendment 80 limited access fishery is closed by the Regional Administrator; or
Until the permit is revoked, suspended, or modified pursuant to § 679.43 or under
15 CFR part 904.
●
A legible copy of the Amendment 80 CQ Permit must be carried on board
the Amendment 80 vessels assigned to the Amendment 80 Cooperative.
Type or print legibly in ink; retain a copy of completed application for your records.
Completed forms should be mailed or faxed to:
NMFS Alaska Region
Restricted Access Management
P.O. Box 21668
Juneau, AK 99802-1668
FAX: (907) 586-7354
If you need additional information, contact Restricted Access Management at (800) 304-4846 (#2)
or (907) 586-7202 (#2).
Please allow at least 10 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.
Amendment 80 Cooperative CQ Permit
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OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
BLOCK A -- AMENDMENT 80 COOPERATIVE IDENTIFICATION
In addition to the information required above, an Amendment 80 harvester who wishes to participate
in an Amendment 80 cooperative for a calendar year must provide the following information:
Cooperative's legal name
Type of business entity under which the Amendment 80 Cooperative is organized
State in which the Amendment 80 Cooperative is legally registered as a business entity
Permanent business address
Business telephone number, business fax number, and e-mail address (if available)
Printed name and signature of Amendment 80 designated representative and date signed
BLOCK B – MEMBERS OF THE AMENDMENT 80 COOPERATIVE
Amendment 80 QS Permit Holder and Ownership Documentation
Full name and NMFS Person ID of all members of the Amendment 80 cooperative
Amendment 80 QS Permit Number(s)
Enter the names of all persons, to the individual level, holding an ownership interest in the
Amendment 80 QS Permit Number(s) assigned to the Amendment 80 cooperative and
the percentage ownership each person and individual holds in the Amendment 80 QS Permit(s).
If the Amendment 80 QS Permit Holder is a non-individual (i.e., a corporation, partnership or other
entity), provide the names of, and the percentage of ownership held by, all of its owners. Information
should be provided to the individual level. See example below:
Name of Owner
% Interest
Joe Potpuller
25%
Alice Potpuller
25%
LLP Family Holdings, Inc.
50%
C. A80QSholder
25% (of 50%)
R. A80QSholder
25% (of 50%)
A. A80QSholder
25% (of 50%)
B. A80QSholder
25% (of 50%)
Duplicate the form, or attach a separate sheet of paper if necessary to display all of the
Applicant’s owners (and owners of the Applicant’s owners to the individual level).
BLOCK C – IDENTIFICATION OF AMENDMENT 80 COOPERATIVE MEMBER VESSELS
AND AMENDMENT 80 LLP LICENSES
Identify the Amendment 80 vessels by name, ADF&G vessel registration No., USCG documentation
number, and the Amendment 80 LLP licenses held by all members of the Amendment 80 Cooperative.
Amendment 80 Cooperative CQ Permit
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OMB Control No.: 0648-xxxx
Expiration Date: mm/dd/yyyy
BLOCK D -- IDENTIFICATION OF VESSELS ON WHICH THE CQ ISSUED TO THE
AMENDMENT 80 COOPERATIVE WILL BE USED
Identify the Amendment 80 vessels by name, ADF&G vessel registration No., and USCG documentation
number on which the CQ issued to the Amendment 80 Cooperative will be used.
BLOCK E – EDR SUBMITTAL
Indicate (YES or NO) whether the each member of the Amendment 80 cooperative has submitted a timely
and complete EDR for each Amendment 80 QS permit held by that person as required under § 679.94.
BLOCK F – CERTIFICATION OF COOPERATIVE AUTHORIZED REPRESENTATIVE
The Cooperative Authorized Representative must sign and date the application certifying that all
information is true, correct, and complete to the best of his/her knowledge and belief. Attach
explicit authorization to complete the application on behalf of the members of the cooperative..
PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden 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 the
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 MagnusonStevens Act (16 U.S.C. 1801, et seq.) as amended by Public Law 109-479; 3) Responses to this information request
are confidential under section 402(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.
Amendment 80 Cooperative CQ Permit
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| File Type | application/pdf |
| File Title | C:\PRA\OMB83I pre-ps.WP6.wpd |
| Author | rroberts |
| File Modified | 2007-05-22 |
| File Created | 2007-05-22 |