Form 3-200-75 Registration of a Production Facility for Export of Cert

Expires 07/31/2010
OMB No. 1018-0137

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 212
Arlington, VA 22203
1-800-358-2104 or 703-358-2104

Type of Activity:
Registration of a Production Facility for
Export of Certain Native Species
(Convention on International Trade in Endangered Species)

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
7.a. Business telephone number

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact
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 of $50. 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?
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: _________________________________
Yes
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 3-200-75

Rev. October 2007

Page 1 of 5

ALL APPLICANTS COMPLETE SECTION E: Provide the information requested in Section E below. Be as
complete and descriptive as possible. Please do not send pages that are over 8.5”X 11”, videotapes, or DVDs.
E.
REGISTRATION OF A PRODUCTION FACILITY FOR EXPORT OF NATIVE CITES SPECIES
This application is to be used by qualified production facilities for an annual registration to export certain native species. The
registration will allow the registrant to obtain any number of single-use CITES export documents (at a cost of $5 each) for approved
species. Please contact the Division of Management Authority or see our webpage at www.fws.gov/permits for a list of qualified
species and conditions that must be met to qualify for registration, or to answer any questions you may have. The fee to process this
application is $50.
ALL APPLICANTS MUST PROVIDE:
1. Species to be registered (scientific and common name).
2.

Description of all products and specimen types to be exported (live, whole carcasses, meat, etc.).

3.

Purpose of activity (circle all that apply):
Museum

Commercial

Personal

Exhibition

Scientific Research

Zoological

FOR APPENDIX III SPECIES:
Provide the information requested in 4 and 5 if the registration is for a species listed in Appendix III.
4.

Location of farm or production facility (physical address, including county).

5.

Copies of any licenses or permits required for your farm or production facility under Federal, tribal, State, or local laws or
regulations.

FOR APPENDIX II SPECIES:
Provide the information requested in 6 through 12 if the registration is for a species listed in Appendix II.
6.

Location of farm or production facility (physical address, including county).

7.

Description of your production system (how your specimens are produced; number of male and female breeding stock
maintained at your facility; whether you supplement your stock with individuals collected in the wild; if supplemented from
other sources, provide those sources and how often you supplement).

8.

Copies of any licenses or permits required for your farm or production facility under Federal, tribal, State, or local laws or
regulations

9.

If the specimens for export were taken from the wild, provide:
a) Evidence they were legally taken (e.g., State license and tag number)
b) Purpose for removal from the wild
c) Where specimens were taken (exact location, e.g., closest town, river mile marker, or body of water)
d) Date specimens were taken
e) Gear used to capture specimens

10.

If the specimens for export are captive-bred, provide:
a)
Evidence the animals were captive-bred (breeder’s records, signed breeder’s statement, ISIS documents, etc.)
Please note: If you are not the breeder of the wildlife, you must submit breeder’s records and copies of invoices or
other documents showing that you acquired the wildlife from the breeder. If there have been several owners, show the
history of transactions including invoices for each change of ownership from the time the specimen was harvested until
the time you purchased it.
b)
Evidence that your founder stock was legally taken (e.g., State license and tag number)
c)
Purpose founder stock was removed from the wild
d)
Where founder stock specimens were taken (exact location)
e)
Date they were taken
f)
Gear used to capture founder stock specimens

Form 3-200-75

Rev. October 2007

Page 2 of 5

11.

Estimate of your production for the coming year. If dealing with more than one type of specimen, such as roe and meat, please
provide estimates for each type.

12.

Normal mortality rates at your facility. If you have experienced unexpected or higher than normal mortality rates, disease
breakouts, or contaminant events at your facility during the past five years please provide a brief discussion.

ALL APPLICANTS COMPLETE:
13.

For living wildlife, describe:
a) The type, size, and construction of any shipping container
b) Arrangements for watering or otherwise caring for the wildlife during transport

14.

Address where you wish permit to be mailed:
_________________________________________________________________________.

15.

If you wish the permit to be mailed other than by regular mail, provide air bill, envelope, or billing information:
________________________________________________________________________________.

16.

Who should we contact if we have questions about the application? (Include name, phone number, and email):
____________________________________________________________________________.

17.

Have you obtained all required State, Federal, or foreign government approval(s) to conduct the activity you propose?
Yes
If yes, provide a copy of the approval(s).
Have applied
Not required

Please continue to next page

Form 3-200-75

Rev. October 2007

Page 3 of 5

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 simplification, 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, State, tribal 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 3-200-75

Rev. October 2007

Page 4 of 5

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, 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, 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, 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, state, tribal, 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/an registration of a production facility for export of certain native species application is 30 minutes. 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 3-200-75

Rev. October 2007

Page 5 of 5