Form 3-200-76 Federal Fish and Wildlife Permit Application Form

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: 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 of Caviar or Meat of Paddlefish or Sturgeon
Removed from the Wild (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 indicated on page 2. 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)

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E. NOTE: To ensure the most applicable application is being submitted, please review the following before completing this
form. To request export of live specimens removed from the wild use form 3-200-27; export of aquacultured specimens use
form 3-200-24; re-export of specimens use form 3-200-73; or export or re-export of species listed under the U.S. Endangered
Species Act use form 3-200-37.
Please provide the following information. If necessary, use a separate sheet of paper. On all attachments or additional pages,
please indicate the application question number you are addressing. Please do not use staples.
1.

What type of authorizations are available to me as an exporter?
a. Single shipment for export. The processing fee is $100 per application. Provide the name and address of
person/facility receiving the shipment (if self, provide address abroad).
Name:
Address
City, Country, Postal Code
b. Multiple shipments of identical amounts. For multiple shipments of identical amounts, the Service can establish a
master file. If the master file is approved you would need to obtain single-use permits, valid for 6 months, for each
export (50 CFR 13.11, see attached). The processing fee is $200 and is $5 for each permit issued from the master file
(e.g., shipments to a cruise ship). To obtain single use permits from the master file, complete below:
i.
Total amount you are requesting to be authorized: ____________.
ii. How many permits do you anticipate using in the next 6 months? _________. (Provide $5 for each 6-month
permit; you may provide this after the master file is approved).
iii. Amount you are requesting on each permit:
____________ (must be identical for each permit.)
(EXAMPLE: TOTAL AMOUNT = 100 KG; 4 PERMITS; 25 KG EACH.)
iv. Note, you may either fill in the recipient at the time of export or you may indicate a recipient in block A above.

2.

For each product to be exported, provide:
a.
Scientific name (genus, species, and if applicable, subspecies) and common name of the fish:
b.
State(s) of harvest of source specimens:
.
c.
Product description (caviar or meat):
.
d.
Weight (in metric units) :
e.
Shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units):
f.
Shipment will be fresh, frozen, or pasteurized (circle one), or other (describe) _________________
g.
If caviar, provide list of labels (see enclosed caviar labeling requirements).
h.
Current location of specimen(s): _________________________________________.

.

.
.

3.

What is the purpose of the export? Check one:  Commercial  Personal

 Other: _______________

4.

Does this application request authorization to export a portion of a product(s) that was authorized under a previous permit?
a.
If no, continue to question 5.
b.
If yes, complete c. and d. below and continue to questions 11-14.
c.
Provide a copy of the cleared 3-177 declaration form obtained when you exported the previous portion of product,
and complete and sign (in ink) the following statement:
d.
I hereby certify that the product pertaining to this current application is a portion of the product previously
authorized for export under permit number _______________________.
(fill in permit number)
Signature and date ____________________________________________________________________.

Numbers 5-10 must be answered for the entire quantity of product(s) listed in your application. By signing this application, you
are certifying that to the best of your knowledge and belief all the information provided in support of this application is complete
and accurate, including any and all information provided about suppliers, dealers, and fishers.
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5.

List ALL intermediary suppliers’ and/or dealers’ names and addresses below and weight of product obtained from each
(attach additional sheets of paper as necessary):
Name:
Address:
City, State, Zip Code:
Total weight of product
supplied:

6.

List ALL fishers’ full names and addresses below and weight of product obtained from each (attach additional sheets of
paper as necessary):
Name:
Address:
City, State, Zip Code
Total weight of product
supplied:

NOTE for numbers 7-10: If you obtained product(s) from a supplier or dealer, you must obtain, and supply to us, all of
the required information from the supplier. All supporting documentation must be submitted in an organized format;
otherwise the application will not be processed and will be returned to you. Documentation should be organized first by
State of harvest (i.e., all documentation for fish harvested from a particular state must be clipped together). Within each
State packet, the documentation should be grouped by fisher (i.e., every invoice for a particular fisher must be clipped
together).
7.

Provide a copy of the appropriate commercial buyer’s license(s).

8.

For each fisher listed above, provide a copy of the current license(s), permit(s), or other documents issued by the State or
local wildlife authorities approving the commercial fishing activities.

9.

Provide copies of each fisher’s State harvest report for the product(s) to be exported. The harvest report should include, at
a minimum, the following information. If any of this information is not listed on the fisher’s harvest report, the
information must be provided separately for each fisher on an attached sheet of paper. For each fisher provide the:
a. Dates the fish were harvested;
b. Harvest location(s), including the State, county(ies), body of water, AND the nearest mile marker or boat ramp to each
harvest location; and
c. Gear used to harvest or collect the fish.

10.

Provide copies of documentation showing the transfer of ownership (e.g., dated sales receipts/invoices) of the product
from each fisher or supplier to you. If you received the product from a supplier(s) or source other than the harvesters of
the fish, provide documentation demonstrating the history of transactions (chain of ownership of the product) from the
fisher(s) to you. You must be able to provide documentation for EACH change in ownership from the time of harvest
until the time you purchased the product.

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11.

Enter the U.S. port through which the [export/re-export/import] 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.)

12.

Address where you wish permit mailed (if different than page 1):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.

13.

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:
_______________________________________________________________________________________

14.

Who within your company, should we contact if we have questions about the application, if different than in section B?
(Include name, phone number, and email): ____________________________________________________.
Note that it is our policy to contact only the applicant, and only if additional information is required.

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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 of Caviar or Meat of Paddlefish or Sturgeon Removed from the Wild (CITES) application is 3 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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