Form 3-200-72 Eagle Nest Take - Safety Emergency

Expires xx/xx/xxxx
OMB No. 1018-xxxx

Department of the Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form

Return to: Migratory Bird Permit Office
U.S. Fish and Wildlife Service
[address]
[address]
[phone]

Type of Activity:
Eagle Nest Take – Safety Emergency

Complete section A or B, and sections C and D of this application. See attached Permit Application Instructions.

A.

Complete if applying as an individual

1.a. Last name:

1.b. First name:

1.c. Middle name or initial:

1.e Doing business as (dba):

2.a. Mailing Address (line 1):

2.b. Mailing Address (line 2):

2.c. Mailing Address (line 3):

3.e. Zip code/postal code :

3.a. City:

3.b County:

3.b. Country:

6. Occupation:

1.d. Suffix

3.c Province:

4. Date of birth (mm/dd/yyyy):

3.d. State:

5. Social Security No:

7. List of any business, agency, organizational, or institutional affiliation associated with the wildlife or plants to
be covered by this permit:

8. Home telephone number:

B.

9. Work telephone number:

10. Fax number:

11. E-mail address:

Complete if applying as a business, corporation, public agency or institution

1.a. Name of business, agency, or institution:

3.a. Mailing address (line 1):

1.b. Doing business as (dba):

3.b. Mailing address (line 2):

4.a. City:

4.b. County

2. Tax identification no.:

3.c. Mailing address (line 3):

4.c. State:

4.d. Zip code:

5.a. Principal officer - Last name:

5.b. First name:

5.e. Principal officer title:

6. Describe the type of business, agency, or institution and provide State of incorporation:

7. Home telephone number:

8. Work telephone number:

C

9. Fax number:

5.c. Middle name or initial

5.d. Suffix

10. E-mail address:

All applicants complete

1. Do you currently have or have you had any Federal fish and wildlife permits? (For simplicity, all licenses, permits, registrations, and certificates

will be referred to as a permit.)
Yes

If yes, list the number(s) of the most current permit you have held:

No

2. Application fee: Enclose a check or money order payable to the U.S. Fish and Wildlife Service in the amount of $300.00 if you are applying for a

new permit or $150.00 if you are requesting a substantive amendment of your existing valid permit. Federal, tribal, State, and local government
agencies, and individuals and institutions acting on behalf of such agencies, are exempt from the application processing fee upon submission of a
letter (on agency letterhead) certifying that the applicant is acting on behalf of the government agency (50 CFR 13.11(d)).
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. 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 Photocopies or stamped signatures)

Date of signature (mm/dd/yyyy)

Form 3-200-72, REV 05/07

Please continue to Section D on next page

Page 1of 2

D. EAGLE EMERGENCY NEST TAKE (Eagle Act, 50 CFR 22.27)
An eagle emergency nest take permit authorizes the removal of bald or golden nests for human safety or the
safety of eagles. Permits are available to individuals, agencies, businesses, and other organizations.
Please be as specific as possible in your responses to the questions below. We strongly recommend that you
submit your application at least 60 days prior to the date that you need your permit, as required by 50 CFR
13.11(c).
Provide the following information on a separate sheet of paper. Please be as specific as possible in your
responses to the questions. Please do not send pages that are over 8.5”X11”, videotapes, or DVDs.
1.

A description of your proposed activity that will likely take eagles, including:
(A) The number of nests proposed to be taken, whether the nest(s) is a bald eagle or golden eagle nest, and
whether the nest(s) is active or inactive;
(B) Why the removal of each nest is necessary to alleviate safety concerns;
(C) A description of the property, including maps and digital photographs that show the location of the nest in
relation to buildings, infrastructure, and human activities;
(D) The location of the property, including latitude and longitude;
(E) The length of time for which the permit is requested, including beginning and ending dates; and
(F) A statement indicating the intended disposition of the nest, and if active, the nestlings or eggs.

2. You must retain records relating to the activities conducted under your permit for at least 5 years from the date of
expiration of the permit. Please provide the address where these records will be kept.

3. Have you obtained all required State, Federal or foreign government approval(s) to conduct the activity you
propose?
If yes, provide a copy of the approval(s).

Form 3-200-72, REV 05/07

Have applied

Not required

Page 2 of 2

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
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.
•

Complete section A or B, and sections C and D of the application. Print clearly or type in the information. An incomplete or unclear
application may cause delays in processing or may be returned to the applicant.

•

Provide any required additional information or attachments outlined in section D of the application form. Be as complete and descriptive
as possible. If there is any doubt as to the information's relevance, include it with the application.

•

Sign the application in blue ink and send the original to the address at the top of the application. Faxes or copies of the original signature
will not be accepted.

•

Please plan ahead. Allow at least 60 days for your application to be processed (50 CFR 13.11). Some applications may take longer than
90 days to process. Applications are processed in the order they are received.

•

Additional forms and instructions, as well as regulations, are available on the Internet at http://permits.fws.gov/.

Most of the application form is self-explanatory, but the following provides some assistance for completing the form.
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. All blocks must be completed. If you are applying as an
individual but conducting permitted activities as a business, provide the name of the business. If you are applying on behalf
of a client, the personal information must pertain to the client. A document evidencing power of attorney must be included with the
application.

Section B.

"Complete if applying as a business, corporation, public agency, or institution" - Enter the complete name and address of the
business, agency, institution, or other organization that will be the permittee if a permit is issued. Give a brief description of the type
of business or activity the applicant is engaged in, the name and phone number of the person in charge (i.e., principal officer), and if
the company is incorporated, the State in which it is incorporated.

ALL APPLICANTS COMPLETE SECTION C:
Block C.1

"Do you currently have or have you had any 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. (Do not list permits of others under which you
acted as a subpermittee or agent.)

Block C.2

"Application fee:” - You must enclose a permit processing fee unless you are fee exempt. Consult the Application Processing Fee
section on the next page. Make your check or money order payable to the “U.S. Fish and Wildlife Service” and attach it to the
application form. If you are fee exempt, write “EXEMPT” in the fee block and attach proof of exempt status with your application.

Block C.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 before signing.

ALL APPLICANTS COMPLETE SECTION D:
Provide any required additional information outlined in Section D of the application form. Be as complete and descriptive as possible. If
there is any doubt as to the information’s relevance, include it with the application.
In response to "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 local zoning requirements. If "yes,"
list the State, Federal or foreign countries involved and type of document required. Include a copy of these documents with the
application. If "no," indicate what steps you have taken to secure approval (use attachment if necessary). If you have applied for the
documents, check the “have applied” box and list the State, Federal or foreign countries involved and type of documents required. If the
proposed activity is not regulated check "not required."

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT
Paperwork Reduction Act and the Privacy 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 that:
1.

The gathering of information on fish and wildlife is authorized by:
(a)
Bald and Golden Eagle Protection Act (16 U.S.C. 668), Title 50, Part 22, of the Code of Federal Regulations (CFR);
(b)
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), Title 50, CFR Part 17;
(c)
Migratory Bird Treaty Act (16 U.S.C. 703-712), Title 50, CFR Part 21;
(d)

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

(e)
(f)
(g)
(h)
(i)
(j)

Wild Bird Conservation Act (16 U.S.C. 4901-4916), Title 50, CFR Part 15;
Lacey Act (18 U.S.C. 42); Injurious Wildlife, Title 50 CFR Part 16;
Convention on International Trade in Endangered Species of Wild Flora and Fauna (CITES) (TIAS 8249); Title 50, CFR Part 23.
General Provisions, Title 50 CFR Part 10;
General Permit Procedures, Title 50 CFR Part 13; and
Wildlife (Import/export/transport), Title 50 CFR Part 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 the 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. 1371-1383) 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 if the disclosure is compatible with the purposes for which
the record was collected. (Ref. 68 FR 52611, September 4, 2003)
(a) To subject matter experts, State, Federal, 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) 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) To Federal, 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) 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) To Federal, 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) 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) To the appropriate Federal, State, tribal, 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) To a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
(i) To the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
(j) 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 eagle incidental take application is 6 hours, and 2-6 hours for monitoring and reporting. 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)].
Application Processing Fee
The fee to process an eagle nest take permit application is $300.00. This fee applies to new permit applications and permit renewals. The fee to process a substantive
amendment to an existing valid permit is $150.00. Substantive amendments are those that pertain to the purpose and conditions of the permit and are not purely
administrative. Administrative changes, such as updating name and address information, are required under 50 CFR 13.23(c), and such amendments do not require a fee.
Checks should be made payable to AU.S. Fish and Wildlife Service.@ The fee does not guarantee the issuance of a permit. It will not be refunded regardless of whether a
permit is issued, abandoned, or denied. We will not refund any application fee under any circumstances if we have processed the application. However, we may return the
application fee if you withdraw the application before we have significantly processed it. (50 CFR 13.11(d))
The application fee does not apply to any Federal, tribal, State, or local government agency or to any individual or institution acting on behalf of such agency for the
proposed activities.

Form 3-200-72, REV 05/07