Pacific Coast Groundfish Limited Entry Permit Renewal

OMB Control No. 0648-0203
Expiration Date: 09/30/2009

PERMIT RENEWAL FORM
PACIFIC COAST GROUNDFISH
Limited Entry Permit

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
Northwest Region , Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353
www.nwr.noaa.gov

Fax (206) 526-4461

Please make any changes as appropriate to the addresses, phone and fax number and email address listed below.
Please sign, date and return the form with payment. Any changes in vessel registered to the permit, or a change
of a permit or vessel owner will require submission of a permit transfer form.
Permit Number:
Permit Owner:
Permit Owner's name(s):
Business Address:
Business Phone:
Fax Number:
Email address:
Date of Birth (For each individual given):
Vessel Owner:
Vessel Owner name (s):
Business address:
Business phone:
Fax number:
Email address
Date of Birth (For each individual given):
Vessel name
Vessel Official number
Endorsements (Gear, Size):
Please sign below to certify that the above information is true, correct and complete (edit if necessary) to the
best of your knowledge and return this form with a check or money order for $110.00 made payable to U.S.
Department of Commerce, NOAA. Mail to: NOAA/NMFS/Northwest Region, Sustainable Fisheries
Division, 7600 Sand Point Way NE, Bldg. #1 Seattle, WA 98115-0070.
____________________________________________________________________________
Signature of owner(s)
Title (If corporate officer)
Date
Print Name of Signatory: __________________________
Warning Statement: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15
CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and as a federal crime under 18 USC 1001
PRIVACY ACT STATEMENT: Your date of birth is confidential and is protected under the Privacy Act. Provision of your date of
birth is mandatory as part of this collection. The primary purposes for requiring the date of birth is to verify the identity of
individuals/entities doing business with the government as required by the Debt Collection Improvement Act of 1996 (Public Law
104-134) and for enforcement activities.
The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United
States Federally Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became
effective on June 11, 2008 (73 FR 33065).

OMB Control No. 0648-0203
Expiration Date: 09/30/2009

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.33 hours per response, including
the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest Region, Attn:
Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115.
ADDITIONAL INFORMATION: Before completing this form, please note the following: 1) This information is collected to manage and
conserve the Pacific Coast Groundfish fishery and more specifically, to maintain accurate and current records on all permit owners, permit
holders and vessels registered to participate in the Pacific Coast Groundfish Limited Entry Program. This information will be used to
formally document a request from the permit owner to make a change to a permit and allow the Agency to review and verify that such a
request is in compliance with existing regulations, to monitor and analyze changes in participation in Pacific Groundfish fishery, accurately
record changes to the listed permit owner, permit holder or vessel registered to the permit, and maintain accurate and current address and
contact information of permit owners and holders to allow the Agency to notify them of changes in the fishery regulations. 2) This
collection of information is mandatory and a change in registration of limited entry permits is required at 50 CFR Section 660.335 (b-i). 3)
Responses to this information request are confidential under Section 402(b) of the Magnuson-Stevens Act (16 U.S.C. 1801, et. seq.). It is
also confidential under NOAA Administrative Order 216-100, which sets forth procedures to protect confidentiality of fishery statistics.
These procedures have been implemented under the NMFS Operations Manual entitled, “Data Security Handbook of the Northwest and
Alaska Region, National Marine Fisheries Service”. Not withstanding 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 Number.