Form 3-200-10b Federal Fish and Wildlife Permit Application Form

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OMB No. 1018-0022

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

Return to: U.S. Fish and Wildlife Service (USFWS)
or

Type of Activity:

Rehabilitation

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

5. Principal officer title

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact

7.a. Business telephone number

7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail 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

D.
1.

2.

3.

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete
Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount $50.00.. 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))
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
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

Form 3-200-10b

Rev. 7/2007

Page 1of 5

E. REHABILITATION
(Migratory Bird Treaty Act, 50 CFR 21.31)
Note: A Federal Rehabilitation permit is required to acquire, temporarily possess, or transport sick and injured migratory birds, restore them to
health, and release them back to the wild. Birds undergoing rehabilitation may not be displayed to the public. Permits are available to
individuals and organizations with appropriate facilities as described in the NWRA/IWRC Minimum Standards for Wildlife Rehabilitation and
demonstrated experience in rehabilitating migratory birds. You must be at least 18 years old to apply. A rehabilitation permit may be valid up to
5 years. Please read “What You Should Know About A Migratory Bird Rehabilitation Permit” and the pertinent regulations before you sign and
submit your application.
Please provide the following information on a separate sheet of paper:
1.

What groups of species do you intend to rehabilitate?
____ Songbirds/Passerines ____ Waterbirds
____ Waterfowl
____ Seabirds
____ Raptors ____ Eagles ____ Other:___________________________________________________________________

2.

(a) Describe in detail your experience and training, including the source and the duration, in treating and rehabilitating migratory birds. List
the species you have worked with and the approximate number of hours or years of experience in each of the following areas:
i) handling, capturing, and restraining
ii) transporting
iii) providing daily care and feeding; and
iv) the types of medical treatments provided and management of injuries.
(b) Provide the name, address, and telephone number of the facility where your experience was obtained.

3.

Provide a letter of recommendation from a federally permitted rehabilitator familiar with your training and experience. Also attach a letter
from a federally permitted rehabilitator stating his or her willingness to provide you with assistance. If these are the same individual, a single
letter will suffice.

4.

Describe how birds will be conditioned for release. If you will use creance flying, describe in detail the techniques you will use and your
experience with these techniques. If you propose to use a flight cage and do not own one, provide a letter from a licensed rehabilitator stating
his or her willingness to allow you the use of their enclosure(s).

5.

Describe your rehabilitation facilities for restricted, limited, and unlimited care. Attach photographs and diagrams of your indoor and outdoor
enclosures. Diagrams must include dimensions (width, length, and height) and a description of interior and exterior construction materials,
such as flooring and netting materials. Indicate the species or type of species to be housed in each. If your facilities are not physically located
at the mailing or physical address provided on page 1, section C.1., of this application provide the physical location (street address or legal
description).

6.

Describe the diet you will administer for each group of species you propose to rehabilitate, and indicate your food source.

7.

Provide the name and telephone number of your State Wildlife Law Enforcement contact.

8.

Subpermittees: Please provide the name of anyone who will be responsible for the permitted activities in your absence. Anyone authorized to
conduct permitted activities in your absence must be at least 18 years old. If a subpermittee will be authorized to rehabilitate migratory birds
at a site other than your facility, provide the following information: name; address; age; description of their migratory bird rehabilitation
experience; type of species they will care for; type of care they will provide; diagrams (width, length, and height dimensions) and, except for
persons raising baby passerines, photographs of their facilities. If permitted activities will take place at a location other than your facility, the
facilities at that location must be pre-approved. Any individual(s) regularly transporting birds directly to your facility or from your facility
directly to another facility must either be listed under your permit as a subpermittee or possess their own rehabilitation permit. As the primary
permittee, you are legally responsible for ensuring that your subpermitees, staff, and volunteers adhere to the terms of your permit when
conducting migratory bird rehabilitation activities. Some states may require Federal subpermittees to have their own state permit.

9. Attach a letter from a licensed veterinarian stating their willingness to work with you by providing any necessary veterinary assistance.
10. You must retain records of each migratory bird you receive for at least 5 years following the end of the calendar year covered by the records.
The records must include the date each bird is received, type of injury or illness, disposition, and date of disposition.
Is the physical address you provided in Section C on page 1 of this application the address where your records will be kept?
____ Yes
____ No If “no”, provide the physical address. _____________________________________________________________
11. Have you obtained all required State permits or approvals to conduct this activity?
____ Yes If “yes”, attach a copy of the approval(s).
____ Have applied
____ None required
12. If you are operating as a private individual, indicate if the Service may include your name, address, and telephone number in a public list of
permitted migratory bird rehabilitators? (See attached explanation.) ____Yes
____ No

Form 3-200-10b

Rev. 7/2007

Page 2 of 5

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
Form 3-200-10b

Rev. 7/2007

Page 3 of 5

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.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;
Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;
Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;
Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/ , 50 CFR 23;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
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.
b.
c.
d.
e.

f.
g.
h.
i.
j.

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.
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.
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.
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.
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.
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.
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.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
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 a Rehabilitation permit application is 7 hours for the application and 5 hours for recordkeeping . 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 3-200-10b

Rev. 7/2007

Page 4 of 5

Explanation of Request for Permission to Release Contact Information
About Federally Permitted Migratory Bird Rehabilitators
(Section E., Question 12)
The Fish and Wildlife Service often is asked for the names, addresses, phone numbers, and species specialty
of federally permitted rehabilitators. This information may be requested by State or local officials or by the
general public. We are obligated to provide this information for permittees that operate as businesses and
organizations. However, the records for individuals holding migratory bird permits are contained in a
Privacy Act (5 U.S.C. 552a) system of records. Therefore, only the name, species, permit number, and State
of residence of private individuals are automatically included on any list of permittees made available to the
public.
To better serve the public and help facilitate prompt treatment of sick and injured migratory birds, we intend
to compile a list of names and contact information for federally permitted migratory bird rehabilitators. This
list will be posted on our website and made available to the operators of our 1-800-344-WILD information
line. The complete address and phone number of private individuals will be included only upon authorization
from those permittees.
For those who elect to withhold address and phone numbers from the public list, the Service will only release
such information as provided in the Privacy Act, or under the Freedom of Information Act upon a
determination that the release would be in the public interest, such as may be necessary to control zoonotic
disease.

Form 3-200-10b

Rev. 7/2007

Page 5 of 5