Form 3-200-10e 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: Special Purpose – Migratory Game Bird Propagation

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 $75.00 .. 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 3-200-10e

Rev. 7/2007

Page 1of 4

E.

SPECIAL PURPOSE - MIGRATORY GAME BIRD PROPAGATION
(Migratory Bird Treaty Act, 50 CFR 21.27)

Note: A Federal Special Purpose - Migratory Game Bird Propagation Permit is required to possess, propagate, purchase, sell,
and barter captive-reared, properly marked migratory game birds, other than waterfowl. Migratory game birds are listed in the
regulations at 50 CFR 20.11. All migratory game birds held or transferred under the permit must be marked in accordance with
50 CFR 21.13(b). Please read “What You Should Know About A Migratory Bird Special Purpose Game Bird Permit” and the
pertinent regulations before you sign and submit your application.
Please provide the following information in the space provided or on a separate sheet of paper:
1.

List the species of migratory game birds, other than waterfowl, you plan to acquire.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

2.

Are your facilities located at the mailing or physical address you provided on page 1, section C.1., of this application?
____Yes
____ No If “no,” provide the location (street address or legal description).
_____________________________________________________________________________________________

3.

Describe the facilities where the game birds will be held. Attach diagrams and photographs of your enclosures, including
dimensions (length, width, and height).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

4.

Which of the following methods will you use to mark progeny?
____ Remove hind toe of right foot
____ Pinion one wing
____ Band one leg with a seamless leg band
____ Tattoo web of one foot

5.

Provide the name, address and Federal permit number of the person from whom you will acquire the birds.
_______________________________________________________________________________________________
_______________________________________________________________________________________________

6.

You must retain records relating to the activities conducted under your permit for at least 5 years after the date of expiration of
your permit. 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.
________________________________________________________________________________________________

7.

Have you obtained all required State permits or approvals to conduct this activity?
____Yes If “yes”, provide a copy of the approval(s).
____ Have applied

Form 3-200-10e

Rev. 7/2007

____ None required
Page 2 of 4

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 3-200-10e

Rev. 7/2007

Page 3 of 4

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 Special Purpose – Migratory Game Bird Propagation permit application is 1 hour, and 30 minutes 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 3-200-10e

Rev. 7/2007

Page 4 of 4