Form 3-200-53 Federal Fish and Wildlife Permit Application Form

Expires XX/XX/XXXX
OMB No. 1018-0093

Department of the Interior
U.S. Fish and Wildlife Service

Federal Fish and Wildlife Permit Application Form
Return to: Division of Management Authority (DMA)
U.S. Fish and Wildlife Service
4401 N. Fairfax Drive, Room 700
Arlington, VA 22203
1-800-358-2104 or 703-358-2104

Type of Activity:

Export/Re-Export of Live Captive-Held
Marine Mammals (CITES)

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

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

D.

All applicants MUST complete

1.

Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $100. 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

2.

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, 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 3-200-53

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E. Export/Re-Export of Live Captive-Held Marine Mammals (CITES)
Note: This application is for the export or re-export of captive-held LIVE marine mammals under the Convention on
International Trade in Endangered Species of Wild Fauna and Flora (CITES). This application is NOT for the
collection (TAKE) of live animals from the wild; for these activities, use form 3-200-43 for U.S. Fish and Wildlife
Service (FWS) species, or for whales, porpoises, and seals contact the National Marine Fisheries Service (NMFS),
Office of Protected Resources, 1315 East-West Highway, Silver Spring, Maryland 20910 (phone: 301-713-2289; fax:
301-713-0376).
For what activity are you requesting authorization to carry out (check the appropriate box):
 EXPORT = $100



Re-export = $75

What is the purpose of the export/re-export (check the appropriate box):
 PUBLIC DISPLAY



SCIENTIFIC RESEARCH

 ENHANCEMENT OF SURVIVAL OR RECOVERY
Please provide the following information. Complete all questions on the application. Mark questions that are not
applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit,
please indicate the application question number you are addressing. If you are applying to export/re-export multiple
animals, be sure to indicate which animal you are addressing in each response.
1. Provide the following for EACH animal you are applying:
a. Scientific name (genus, species, and if applicable, subspecies);
b. Common name;
c. Birth date/Age;
d. Sex (if known);
e. Description (e.g. I.D. #, ISIS #, tattoo #);
f. Country where the wildlife originated;
g. Indicate if the wildlife was originally taken from the wild or born in captivity; and
h. Current location of the specimen.
2. What is the purpose of the export/re-export?
_________________________________________________________________________________
3. For animals previously taken from the wild, or imported provide a copy of the Marine Mammal Protection Act
(MMPA) authorization demonstrating that the specimens were legally obtained.
4. For captive-born wildlife, provide an ARKS/ZIMS report OR:
a. If the animal was born at your facility, please provide a statement that includes:
i.
Birth date, sex, and identification number of each specimen;
ii.
Name and address of your facility where the animal was born;
iii. Location and source (e.g., captive-born, wild-caught) of parental stock; and
iv. Your signature and date.
b. If the animal was born at another facility, provide a signed statement from the facility detailing the origin of
the animal and records that include:
i.
The complete name and address of the facility where the animal was born;
ii.
Birth date, sex, and identification number of each specimen;
iii. Location and source (e.g., captive-born, wild-caught) of parental stock; and
iv. Copies of documentation showing that you acquired the animal from the facility or documentation
demonstrating the history of transactions (chain of ownership of each animal).

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5. If the specimen is being re-exported (exporting a specimen that was previously imported into the United States)
provide:
a. A copy of the canceled CITES export or re-export document issued by the appropriate CITES office in the
country from which the wildlife was imported (if applicable); and
b. A cleared copy of Form 3-177, wildlife Declaration for Import (hard copy or electronic release); or
c. If you did not make the original import, provide a copy of the importer's documents outlined above and the
invoice or other documentation that shows you acquired the wildlife from the original importer or history of
transactions which demonstrate chain of ownership.
6. Provide the name and address of the person receiving the shipment in the foreign country (if self, provide address
abroad).
Name:
Address
City, Country, Postal Code
7. If the animal was obtained prior to the date CITES applied to it (“pre-Convention”), provide documents, signed
statement, or other evidence to that effect. The listing date can be found at http://www.cites.org.
8. For CITES Appendix-I species, provide a copy of the foreign CITES import permit, or evidence one will be
issued by the Management Authority of the country to which you plan to export or re-export the wildlife. (In
accordance with Article III of the CITES Treaty, it is required that import permits are issued before the
corresponding export permit.)
9. For whales, porpoises, and seals provide either a copy of the NOAA Fisheries letter of authorization or evidence
that NOAA Fisheries has been contacted.
Questions 10 through 14 apply only for the export or re-export of FWS species
10. Provide a copy of the letter from the U.S. Department of Agriculture (USDA), Animal and Plant Health
Inspection Service, confirming that the foreign recipient meets comparable standards under the Animal Welfare
Act for maintenance and care of marine mammals.
11. For Public Display, provide certification from the importer’s relevant foreign authority (e.g. provincial or
national government) that:
a. The foreign recipient maintains their facility for public display of marine mammals;
b. the facility is open to the public on a regularly scheduled basis;
c. access to such facilities is not limited or restricted other than by charging an admission fee; and
d. the recipient offers a program for education or conservation purposes that is based on professionally
recognized standards of the public display community (include copies of outreach/educational materials,
photos of signage, etc., along with an English translation).
12. For Scientific Research provide information indicating that the export of the animal meets the MMPA definition
of “bona fide research,” i.e., scientific research on marine mammals, the results of which—(A) likely would be
accepted for publication in a referred scientific journal; (B) are likely to contribute to the basic knowledge of
marine mammal biology or ecology; or (C) are likely to identify, evaluate, or resolve conservation problems.
13. For Enhancement, explain the purpose of the export/re-export and provide a description of how the proposed
activities will enhance or benefit the wild population (e.g., in-situ or ex-situ conservation; recovery plan.).

14. Provide a certification from the appropriate government agency of the importing country to show that:
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a.
b.
c.
d.

The laws and regulations of that government allow enforcement of the U.S. permit conditions;
such conditions will be enforced;
the government will afford comity to the USFWS to amend, suspend or revoke the permit, if issued; and
the documents provided by and about the foreign facility are true and correct.

15. The transport conditions must comply with the CITES Guidelines for Transport of Live Animals or, in the case of
air transport, with the International Air Transport Association (IATA) live animal regulations (contact airline for
information). You must also meet USDA standards for Humane and Healthful Transport of Marine Mammals.
As such, provide:
a. The means and duration of transportation;
b. A description of the type, size, and construction of any shipping container;
c. The arrangements for watering or otherwise caring for the wildlife during transport,
d. The qualifications of the person(s) accompanying the wildlife;
e. Documentation showing compliance with USDA regulations for transport and care of live marine mammals
(7 U.S.C. 2131-2159; 9 CFR 3, Part E).
16. Enter the U.S. port through which the export/re-export will occur. ___________________________________
(All wildlife, including parts and products, must be declared to and inspected by a Wildlife Inspector from the
U.S. Fish and Wildlife Service Office of Law Enforcement. A list of designated ports (where an inspector is
posted) is available at http://www.fws.gov/le/ImpExp/Contact_Info_Ports.htm.)
17. Address where you wish permit mailed (if different than page 1):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
18. If you wish the permit to be sent to you by means other than regular mail, provide an air bill, pre-paid
envelope, or billing information:
______________________________________________________________________________________
19. Who should we contact if we have questions about the application? (Include name, phone number, and email):
______________________________________________________________________________________

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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.

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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
an Export/Re-Export of Live Captive-Held Marine Mammals application is 2 hours. 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)].

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