American Samoa Pelagic Longline Limited Access Fishery P

FEDERAL FISHERIES APPLICATION FORM

For Office Use
Reviewed _______
Issued
_______
Transmit _______

OMB Control No: 0648-0490
Expiration Date: 04/30/2008

PACIFIC ISLANDS REGION
NATIONAL MARINE FISHERIES SERVICE
1601 Kapiolani Blvd., Suite 1110
Honolulu, HI 96814-4700
Ph: (808) 944-2200

PLEASE PRINT RESPONSES
Version: 03/10/2008

American Samoa Pelagic Longline Limited Access Program
Limited Entry Permit Application

Application Type: Please check the appropriate box. MAIL or DELIVER (do not fax) completed application to Pacific Islands Region.

Non-Refundable Application Processing Fee: $32.00, payable by check or money order to: Department of Commerce, NOAA.
(Charged for all permit transactions except registration of vessel)
Permit Renewal: (renew existing permit)
Additional Permit Issuance: Please indicate vessel size classification:
G Class A = 40’ or less
G Class B = 40.1’ – 50’
G Class C = 50.1’ – 70’

G Class D = 70’ or larger

Registration of vessel to permit or registration of a different vessel to permit. Vessel must be the same size, or smaller, as permitted
vessel size class.
Permit transfer (for permits registered to vessels of size Class A, B, C, or D):
G Family member
G Community organization
G Person with documented participation in the American Samoa
(Class A only)
longline fishery (required in vessel size Class A for Class A only)
NAME: _______________________________________________________ Family Relationship: _______________________
(Print first and last names or name of community organization)
(If Family member is checked)
Permit Upgrade (Only for permit holders with Class A permits. Please indicate vessel class size to which you are upgrading):
G Class B-1 = 40.1’ – 50’
G Class C-1 = 50.1’ – 70’
G Class D-1 = 70’ or larger
[Retired permit number: ________________ ]
NOTE: This option expires 07/31/2009.

_____________________________________________________________________________________________________________________________________________

VESSEL NAME: _______________________________________

VESSEL NUMBER (USCG or AS): ______________________

VESSEL OWNER: ___________________________________________ TAXPAYER IDENTIFICATION NO: __________________
(Print first, middle, and last name or business name)

(if a business)

DATE OF BIRTH (individual) OR INCORPORATION (business) ______________________________________
Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize collection of this information. This information is used to verify the identity of the applicant(s) and
to accurately retrieve confidential records related to federal commercial fishery permits. The primary purpose for requesting the Taxpayer Information Number is for the
collection and reporting on any delinquent amounts arising out of such person’s relationship to the government pursuant to the Debt Collection Improvement Act of 1996 (Public
Law 104-134). Personal information is confidential and protected under the Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.

BUSINESS MAIL ADDRESS: _______________________________________ ________________________ ______ __________
(Number, street, apt.)

(City/Village)

(State)

(Zip)

BUSINESS PHONE: (_____)__________________ HOME PHONE: (_____)_____________ CELL PHONE: (_____)________________
(Please include the area code for each number)

FAX: (_____) ______________

EMAIL: ____________________________________________________

PERMIT APPLICANT:______________________________________ ________________________________ DATE:_______________
[if applicant is an agent, see note 4 below]

(Print first, middle, and last name)

(Signature)

For Permit Transfers Only. (Current permit holder completes and signs as transferor. Receiving permit applicant fills in all above.)
PERMIT TRANSFEROR: ________________________________________
(Current holder)

(Print first, middle, and last name)

______________________________ DATE: ___________
(Signature)

PERMIT NUMBER WHICH IS BEING TRANSFERRED AWAY: __________________________
Please submit the appropriate required documents:
1) Payment for the non-refundable application processing fee, if required.
2) A copy of the vessel’s current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from the state/territorial
agency (undocumented vessel) to register a vessel to the permit.
3) Documented participation in the American Samoa longline fishery if applying for an additional permit, permit upgrade, or transfer.
4) If an agent is submitting the application, provide a signed letter from the permit holder authorizing the permit applicant as their agent.
If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of notification to provide required documents or your
application will be considered abandoned (50 CFR 665.13(c)(2)). It is prohibited to file false information on an application for a fishing permit (50 CFR
665.16(b)).

OMB Control No.: 0648-0490
Expiration Date: 04/30/2008

American Samoa
Pelagic Longline Limited Access Program
Limited Entry Permit Application
SUPPLEMENTARY INFORMATION SHEET
Company/Corporation officers, owners, or partners:
NAME

MAILING ADDRESS

Check boxes are for office use only:

Previous ownership of longline vessel (prior to March 21, 2002): USCG COD _______ or AS VSL Reg. _______

Vessel used to legally harvest Pacific pelagic management unit species with longline gear in the EEZ around American Samoa, and
those fish were landed in American Samoa, at some time on or prior to March 21, 2002

Currently holds Class A permit (for upgrades or additional permits)

Current Protected Species workshop certification (for renewal)

Fished in AS EEZ with longline: _________________
Documented Evidence of Work on AS Longline Fishing Vessel:

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PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 45 minutes for American Samoa longline limited access additional permit issuance, renewal, transfer or
upgrade. Send comments regarding this burden estimate and any other aspects of this collection of information, including suggestions for reducing this burden, to Regional
Administrator, NOAA Fisheries Pacific Islands Regional Office, 1601 Kapiolani Blvd., Suite 1110, Honolulu, Hawaii 9681-4700.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Western Pacific
Region. This will enable NOAA Fisheries and the Western Pacific Fishery Management Council to (a) determine who would be affected by changes in management; (b)
inform license holders of changes in fishery regulations; and (c) determine whether the objectives of the fishery program are being achieved by monitoring entry and exit
patterns and other regulatory changes on person in the regulated fisheries as well as in related fisheries. Responses to the collection are required to obtain the benefit of a
license for the fishery involved (ref. 50 CFR 560.13). Data provided concerning the vessel and/or business of the respondents is handled as confidential under the MagnusonStevens Fishery Conservation and Management Act (Sec. 402 (b)). Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person
be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of
information displays a currently valid OMB Control Numbers.