Form 3-200-54 Enhancement of Survival Permits Associated with Safe Har

Expires XXX. XX, XXXX
OMB No. 1018-0094

Department of the Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form

Return to: U.S. Fish and Wildlife Service (USFWS)

Type of Activity: Native Endangered and Threatened Species –
Enhancement of Survival Permits Associated with
Safe Harbor Agreements &
Candidate Conservation Agreements with Assurances

(see attached list)

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, tribe, or institution

1.a. Name of business, agency, tribe, 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 pages 2-3. 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 3-200-54

Rev. October 2010

Page 1 of 14

** See page 13 for additional instructions on completing the above form. See page 14 for information on the Paperwork
Reduction Act, Privacy Act, and Freedom of Information Act aspects of this application form.

Section E. ALL APPLICANTS COMPLETE SECTION E. Provide the information outlined in Section E. on the following
pages. Be as complete and descriptive as possible. Please do not send pages that are over 8.5” x 11”, videotapes, or DVDs.
ENHANCEMENT OF SURVIVAL PERMITS ASSOCIATED WITH
SAFE HARBOR AGREEMENTS &
CANDIDATE CONSERVATION AGREEMENTS WITH ASSURANCES
What type of agreement are you requesting?



Safe Harbor Agreement
OR
 Candidate Conservation Agreement with Assurances
Have you obtained all required Federal, tribal, State, county, municipal or foreign government approval to conduct the
activity you propose? Please be aware that there may be other requirements necessary to conduct this activity such as an import
permit, collection permit, permission to work on Federal or tribal lands, Federal bird banding permit, Corps of Engineers permits,
Environmental Protection Agency NPDES permits, tribal, State, county or municipal permits, etc.
 Yes. Provide a copy of the approval(s). List the Federal agency, tribe, State, county, municipality or foreign countries
involved and type of document required. Include a copy of these documents with the application.
 I have applied. List the Federal agency, tribe, State, county, municipality or foreign countries involved and type of
documents required. Provide the reasons why the permits have not been issued
_________________________________________________________________________________________
 Not required. The proposed activity is not regulated.
Application Processing Fees
You may update your name, address, telephone number, fax number, or e-mail address in your current application package on file at
any time. These changes are considered an administrative change, and no application processing fee is required. If you wish to make
an administrative change, please fill out page 1 and indicate the information that you are updating. Then check the box below, provide
your permit number, and send the completed pages 1-2 to the appropriate Regional Office (see attached list).
 Administrative change for permit number: ________________________.
If you wish to make changes other than an administrative change, then an application processing fee is required as described below.
The application processing fee for a new Enhancement of Survival permit, or to renew/substantively amend an existing valid permit
(with major changes) is $50. If permit amendment (with minor changes) is required at a time other than renewal, the processing fee is
$25. For additional information on the application processing fee and the requirements to qualify for a fee exemption, please see the
instructions for section D. on page 13.
If the information in your current application package on file has changed in a manner that triggers a substantive amendment or a
change not otherwise specified in the permit or the Safe Harbor Agreement/Candidate Conservation Agreement with Assurances, then
you must apply for a substantive amendment to your valid permit. For example, such major changes may include changes in location,
activity, amount or type of take, or species to be covered by the permit. Please contact our Ecological Services Field Office located
closest to your proposed activity for technical assistance in making this determination. The contact information for our Ecological
Services Field Offices can be found on the U.S. Fish & Wildlife Service’s (Service) office directory web page at
http://www.fws.gov/offices/directory/listofficemap.html.
Check the appropriate box below and enclose check or money order payable to the U.S. Fish and Wildlife Service in the amount of:
 $50 [or  fee exempt (attach justification if required)] for a new permit. Use Option I. below to provide the required
information.
OR
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 $50 [or  fee exempt (attach justification if required)] to renew or substantively amend my existing valid permit (with
major changes) using my current application package on file. Use Options I. and II. below to provide the required
information. Please indicate the information that you are changing.
OR
 $50 [or  fee exempt (attach justification if required)] to renew/re-issue my existing valid permit (without changes) using
my current application package on file. Use Option III. below to provide the requested information.
OR
 $ 25 [or  fee exempt (attach justification if required)] to amend my existing valid permit (with minor changes) at a time
other than permit renewal. Use Options I. and II. below to provide the required information. Please indicate the information
that you are changing.
Please check the type of amendment you are requesting - add species (specify) ________________________________________________________________________________
 add new activity with previously permitted species (specify) _________________________________________________
 add a geographic area

 change in personnel

 other (specify) ____________________________________________________________________________________
If this application includes transfer or succession of a valid Enhancement of Survival permit, please check the box below:
 Transfer or succession of a valid Enhancement of Survival permit associated with a Safe Harbor Agreement or Candidate
Conservation Agreement with Assurances using the current application package on file. No application fee is required.
Application Processing
To expedite a final decision on your application, you are urged to coordinate with us as soon as possible for guidance in
assembling a complete application package, and to send us your complete permit application package at least three months
prior to the start of your proposed activities. If you are renewing or amending a valid permit, your complete application
package must be received at least 30 days prior to the expiration of the valid permit. These time periods begin with our
acceptance of a complete permit application package, and does not include any time required for requesting clarification or
additional information about your application, or the length of time between our request and your response.
The information provided in your permit application will be used to evaluate your application for compliance with the Endangered
Species Act, its implementing regulations (which may require a 30 day public comment period), and with U.S. Fish and Wildlife
Service policy. Receipt and possession of a permit under the Endangered Species Act should be regarded as a privilege, as we must
balance permit issuance with our duties to protect and recover listed species.
Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered
for renewal, re-issuance or amendment.
If your activities may affect species under the authority of the National Marine Fisheries Service (NMFS/NOAA Fisheries), then you
may need to obtain a separate permit from that agency. In addition we share jurisdiction with NMFS/NOAA Fisheries for sea turtles
(e.g., we evaluate applications for permits to conduct activities impacting sea turtles on land, and NMFS/NOAA Fisheries evaluates
applications for permits to conduct activities impacting sea turtles in the marine environment). To apply for a permit to conduct
activities with sea turtles in the marine environment or other species under NMFS/NOAA Fisheries jurisdiction, please contact them
via their permit web page at http://www.nmfs.noaa.gov/pr/permits/
Our general permit regulations at 50 CFR 13.12(a)(9) allow us to collect such other information as we determine that is relevant to the
processing of a permit application. Before you submit an application for an Enhancement of Survival permit, we may require that you
conduct biological surveys to determine which species and/or habitat would be impacted by the activities sought to be covered under
the permit. Biological surveys provide information necessary to develop an adequate Safe Harbor Agreement or Candidate
Conservation Agreement with Assurances, and to assess the biological impacts of the proposed activities. In addition, the information
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Rev.October 2010

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provided in a biological survey can reduce the applicant’s risk of take under Section 9 of the Endangered Species Act by ensuring that
affected species and/or habitat are identified and appropriately covered under the permit.
You are required to obtain a Scientific Purposes, Enhancement of Propagation or Survival permit (commonly called a Recovery
permit) from us before engaging in any biological survey activities that would take listed species. Contact our Ecological Services
Field Office closest to the location of your activity to obtain technical assistance in determining the need for both a biological survey
and a Recovery permit for your survey activity. The contact information for our Ecological Services Field Offices can be found on the
U.S. Fish & Wildlife Service’s office directory web page at http://www.fws.gov/offices/directory/listofficemap.html
If a biological survey is required, you will need to send us your complete Recovery permit application package and have it accepted at
least 3 months prior to commencement of survey activities to facilitate processing of your Recovery permit application. The Recovery
permit application is designated as U.S. Fish & Wildlife Service form # 3-200-55 and can be found on our Endangered Species permit
web page at http://www.fws.gov/forms/3-200-55.pdf.
We maintain a list of Recovery permittees (such as biological consultants) who have authorized the release of their contact information
to third parties for conducting biological surveys on a contract basis. This list is provided to the public at the discretion of each U.S.
Fish and Wildlife Service Regional Office as time and workload allow. Please be aware that this list does not represent an
endorsement by us of any particular permittee.

****************************************************************************************************************
If you are not applying as an individual but as a business, corporation, tribe, institution, or non-Federal public agency (block B. on
page 1 of the application), the person to whom the permit will be issued (e.g., the landowner, president, director, executive director, or
executive officer) is legally responsible for implementing the permit. Although other people under the direct control of the permittee
(e.g., employees, contractors, consultants) receive third party take authorization in their capacity as designees of the permittee, the
individual named as the permittee ultimately is legally responsible for the permit and any activities carried out under the permit except
as otherwise limited in the case of permits issued to State or local government entities under 50 CFR 13.25(e).
****************************************************************************************************************
If you wish to coordinate the processing of this permit application through an authorized agent, and to have that agent represent you
as the primary contact with us, check the box below. Sign (in blue ink) and date the authorization statement, and provide contact
information for your authorized agent.
G I hereby authorize the following person to act as an authorized agent on my behalf in the processing of this permit
application and to furnish, upon request, supplemental information in support of this permit application.
_________________________
signature (in blue ink)

__________________
date

_________________________
please print name legibly

Your Authorized Agent’s Contact Information (please print legibly)
Name: _______________________________
Address:_______________________________
_______________________________
City:

______________________ State: ___________ Zip Code: _________

Telephone: __________________________
Fax: __________________________

Form 3-200-54

Rev.October 2010

E-Mail:

___________________________

Page 4 of 14

ENHANCEMENT OF SURVIVAL PERMIT APPLICATION INSTRUCTIONS
You have 4 options for providing the required information for an Enhancement of Survival permit application.
Enhancement of Survival Permit Application: Option I. New Enhancement of Survival Permit & Supplementary Information
for Renewal or Amendment of an Existing Valid Permit (With Changes).
General permit regulations for the U.S. Fish and Wildlife Service can be found at 50 CFR 13. Regulations for an Enhancement of
Survival permit associated with a Safe Harbor Agreement under the Endangered Species Act can be found at 50 CFR 17.22(c)(1) for
endangered wildlife species and 50 CFR 17.32(c)(1) for threatened wildlife species. Regulations for an Enhancement of Survival
permit associated with a Candidate Conservation Agreement with Assurances under the Endangered Species Act can be found at 50
CFR 17.22(d)(1) for endangered wildlife species and 50 CFR 17.32(d)(1) for threatened wildlife species.
Each landowner who wishes to be covered under a new or amended Enhancement of Survival permit associated with a Safe Harbor
Agreement or Candidate Conservation Agreement with Assurances must also sign (in blue ink) and date the Enhancement of Survival
Permit Application Certification Notice at the end of this application, unless the landowner will be covered under this U.S. Fish and
Wildlife Service Enhancement of Survival permit via another vehicle, such as a certificate of inclusion (50 CFR 13.25(d)). Any
change in the language of the Certification Notice must be reviewed by the Department of the Interior, Office of the Solicitor and
approved by the U.S. Fish & Wildlife Service. The same person who signs in box D. on page 1 of the application must sign the
certification.
If the information in items A. - B. below is already provided in your final Safe Harbor Agreement or final Candidate Conservation
Agreement with Assurances, then you do not have to provide it here. Instead, check the box below and use the spaces provided in
items A. - B. to indicate the page numbers in your Agreement that provide the requested information.


I am not providing the following information for items A. - B. as part of my Enhancement of Survival permit
application, because it is already provided in my final Safe Harbor Agreement or final Candidate Conservation
Agreement with Assurances (copy attached or already submitted).

If the requested information in items A. - B. is not provided in your final Safe Harbor Agreement or final Candidate Conservation
Agreement with Assurances, or you are using Option II. to renew or amend your existing valid Enhancement of Survival permit, then
attach separate pages for the missing information. In order to assist us in processing your request, please provide the item number (A.
1.a., etc.) of the required information before each of your responses. Thank you.
Please ensure that your final Safe Harbor Agreement or Candidate Conservation Agreement with Assurances is attached if it has not
been previously submitted.
If you have previously submitted a final draft Safe Harbor Agreement or Candidate Conservation Agreement with Assurances, please
indicate the document’s date.
Date of final draft Safe Harbor Agreement ________________

Date of final draft Candidate Conservation Agreement with Assurances _______________

Applications for an Enhancement of Survival permit associated with a Safe Harbor Agreement or Candidate Conservation Agreement
with Assurances must provide the following specific information (relevant to the activity) under items A.- B. below in addition to the
general information on pages 1- 4 of this application.
A.

Identify species and activity:
1.

Form 3-200-54

For a new Enhancement of Survival permit:
a.

Provide the common and scientific names of the species requested for coverage in the permit and their
status (endangered (E), threatened (T), proposed endangered (PE), proposed threatened (PT), candidate for
listing (C), or species likely to become a candidate (LC)).

b.

Provide the number, age and sex of such species to the extent known.
Rev.October 2010

Page 5 of 14

2.

c.

Quantify the anticipated effects to their habitat.

d.

Describe each activity associated with your project that would result in the incidental take of each species.

e.

If you are applying for an Enhancement of Survival permit under a Safe Harbor Agreement, please provide
a brief description of the baseline population and habitat conditions for each listed species proposed for
coverage under the Safe Harbor Agreement. (Note: Baseline conditions must be summarized in a manner
appropriate for each covered species, generally in terms of numbers of individuals present or amount of
suitable habitat.)

For an amended Enhancement of Survival permit:
a.

Identify the activities and/or species to be added to your valid permit (provide both the scientific, to the
most specific taxonomic level, and common names), as well as the species’ status (see 1.a. above).

b.

Provide the number, age and sex of such species to the extent known.

c.

If any activities requested in this application differ from those in your valid permit, then for each species
state the current activity, the requested new activity, and how the new activity will impact each species.

d.

Describe each activity associated with your project that would result in the incidental take of each species.

e.

Quantify any anticipated effects to the habitat of each added species.

f.

Identify activities and/or species to be deleted from your valid permit and the reason(s) for the deletion.

Page(s) & source document : _________________________________________

B.

Identify location of the proposed activity:
1.

Provide the name of the State, county, tribal land, and the specific location of the proposed activity site(s). Include a
formal legal description, section/township/range information, county tax parcel number, local address, or any other
identifying property designation that will precisely place the location of the proposed activity site(s).

2.

Provide the total number of acres covered by the Agreement ___________
Is this the total acreage of the parcel? (circle one)

yes

no

3.

Provide the approximate number of acres to be impacted __________

4.

Provide the approximate number of acres to be protected __________

5.

Provide a complete description, including timeframes, for implementation of proposed voluntary management
activities to enhance, restore, or maintain habitat benefiting federally listed, proposed or candidate species, or other
species likely to become candidates.

Page(s) & source document: ___________________________________________
________________________________________________________________________________________________________

Form 3-200-54

Rev.October 2010

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Enhancement of Survival Permit Application: Option II. Renewal or Amendment of an Existing Valid Enhancement of
Survival Permit (With Changes)
Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered
for renewal or amendment.
Sign the following statement if you are proposing to renew or amend an existing valid Enhancement of Survival permit with changes,
including making major changes. Such major changes may include changes in location, activity, amount or type of take, or species to
be covered by the permit.
The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification
language is required under 50 CFR 13.22(a).
I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife
Service Enhancement of Survival permit # ________________ are still current and correct, except for the changes listed in
Option I. above, and hereby request (please check either G renewal or G amendment) of that permit.

_________________________
signature (in blue ink)

__________________
date

__________________________
please print name legibly
Provide a brief description of the changes to your valid permit (answer the appropriate questions for these changes requested under
Enhancement of Survival Permit Application Option I. above). Please submit completed pages 1 - 7 of this application form (along
with the changed information relative to Option I. above) to our Regional Office (see attached list) covering the location of your
proposed activity.
__________________________________________________________________________________________________________

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Rev.October 2010

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Enhancement of Survival Permit Application: Option III. Renewal/Re-issue of an Existing Valid Enhancement of Survival
Permit (Without Changes) Using My Current Application Package On File.
Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered
for renewal or re-issue.
Sign the following statement if you are applying to renew or re-issue an existing valid Enhancement of Survival permit without
changes. If you are proposing changes to your Enhancement of Survival permit, you must use Options I. and II. above.
The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification
language is required under 50 CFR 13.22(a).
I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife
Service Enhancement of Survival permit # ______________ are still current and correct and hereby request (please check
either G renewal or G re-issuance) of that permit without changes.

_________________________
signature (in blue ink)

__________________
date

_________________________
please print name legibly
* Please note: If you have signed the above statement, then your renewal/re-issue request is complete. Please submit this
page and completed pages 1 - 4 of this application to our Regional Office (see attached list) covering the location of your
proposed activity. Requests for renewals/re-issuance must be complete and accepted by the Service no later than 30 days
prior to permit expiration to ensure that your current permit remains in effect while we process your request.
_________________________________________________________________________________________________________

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Enhancement of Survival Permit Application: Option IV. Permit Transfer or Succession of a Permit
Complete the following if you are applying for transfer of an existing valid Enhancement of Survival permit to you or obtaining rights
of succession of an existing valid Enhancement of Survival permit. In addition, you and the current permit holder may also need to
sign an Assumption Agreement. Please contact our Ecological Services Field Office nearest your activity to determine whether you
and the current permit holder need to execute an Assumption Agreement. The contact information for our Ecological Services Field
Offices can be found on the U.S. Fish & Wildlife Service’s office directory web page at
http://www.fws.gov/offices/directory/listofficemap.html
Please indicate the name of the Safe Harbor Agreement or Candidate Conservation Agreement with Assurances to be transferred or
succeeded, and the document’s date.
Name of Safe Harbor Agreement __________________________________________
Date ______________________
Name of Candidate Conservation Agreement with Assurances __________________________________________
Date ______________________
An Assumption Agreement
is

is not

(FWS Ecological Services Field Office to circle one)

required as part of the transfer or succession permit application for the Safe Harbor Agreement or Candidate Conservation
Agreement with Assurances.
________________________________________________________________________________________________________

Form 3-200-54

Rev.October 2010

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Enhancement of Survival Permit Application
Certification Notice
The same person who signs in box D. on page 1 of the application must sign (in blue ink) the following certification.
By submitting this application and receiving an Enhancement of Survival permit pursuant to Section 10(a)(1)(A) of the
Endangered Species Act, I
__________________________________________________________(print name (s)) attest that I/we own the lands
indicated in this application, or have sufficient authority or rights over these lands to implement the measures of the Safe
Harbor Agreement and/or Candidate Conservation Agreement with Assurances covered by the Enhancement of Survival
permit. Further, upon receipt of the Enhancement of Survival permit, I/we agree to conduct the activities as specified in the
Safe Harbor Agreement and/or Candidate Conservation Agreement with Assurances according to the terms and conditions of
the Enhancement of Survival permit and its supporting documents.
__________________________________
signature (in blue ink)

______________
date

__________________________________
please print name legibly

__________________________________
signature (in blue ink)

______________
date

__________________________________
please print name legibly

Form 3-200-54

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USFWS Regional Contacts for Native Endangered & Threatened Species Permits
Pacific Region (Region 1): HI, ID, OR, WA, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and
the Pacific Trust Territories
U.S. Fish and Wildlife Service
Endangered Species Permit Office
911 NE 11th Avenue
Portland, Oregon 97232-4181
Web: http://www.fws.gov/pacific/ecoservices/endangered/index.html
Phone: (503) 231-2071
email: [email protected]
Fax: (503) 231-6243

Southwest Region (Region 2): AZ, NM, OK, and TX
U.S. Fish and Wildlife Service
Endangered Species Permit Office
500 Gold Avenue S.W. (street address)
P.O. Box 1306 (mailing address)
Albuquerque, New Mexico 87103-1306
Web: http://www.fws.gov/southwest/es/EndangeredSpecies/
Phone: (505) 248-6649
email: [email protected]
Fax: (505) 248-6788

Midwest Region (Region 3): IA, IL, IN, MI, MN, MO, OH, and WI
U.S. Fish and Wildlife Service
Endangered Species Permit Office
B.H. Whipple Federal Building
One Federal Drive
Fort Snelling, Minnesota 55111-4056
Web: http://www.fws.gov/midwest/Endangered/
Phone: (612) 713-5343
email: [email protected]
Fax: (612) 713-5292

Southeast Region (Region 4): AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN, and U.S. Virgin Islands
U.S. Fish and Wildlife Service
Endangered Species Permit Office
1875 Century Blvd., Suite 200
Atlanta, Georgia 30345
Web: http://www.fws.gov/southeast/es/#
Phone: (404) 679-7124 (SHA/CCAA coordinator) or (404) 679-7140 (R4 Endangered Species main office)
email: [email protected]
Fax: (404) 679-7081

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Northeast Region (Region 5): CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VA, VT, and WV
U.S. Fish and Wildlife Service
Endangered Species Permit Office
300 Westgate Center Drive
Hadley, MA 01035-9589
Web: http://www.fws.gov/northeast/endangered/
Phone: (413) 253-8628
email: [email protected]
Fax: (413) 253-8482

Mountain-Prairie Region (Region 6): CO, KS, MT, NE, ND, SD, UT, and WY
U.S. Fish and Wildlife Service
Endangered Species Permit Office
Denver Federal Center
P.O. Box 25486
Denver, Colorado 80225-0489
Web: http://www.fws.gov/mountain%2Dprairie/endspp/
Phone: (303) 236-7400
email: [email protected]
Fax: (303) 236-0027

Alaska Region (Region 7): AK
U.S. Fish and Wildlife Service
Endangered Species Permit Office
1011 E. Tudor Road
Anchorage, Alaska 99503-6199
Web: http://alaska.fws.gov/fisheries/endangered/index.htm
Phone: (907) 786-3323
email: [email protected]
Fax: (907) 786-3350

Pacific Southwest Region (Region 8): CA and NV
U.S. Fish and Wildlife Service
Endangered Species Permit Office
2800 Cottage Way, Suite W-2606
Sacramento, California 95825
Web: http://www.fws.gov/cno/es/
Phone: (916) 414-6464
email: [email protected]
Fax: (916) 414-6486

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PERMIT APPLICATION FORM INSTRUCTIONS
The following instructions pertain to 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 are referred to as a permit.
GENERAL INSTRUCTIONS:

Complete all blocks/lines/questions in Sections A or B, and in C, D, and 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, tribe, or institution:

Enter the complete name of the business, agency, tribe, 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.
ALL APPLICANTS COMPLETE SECTION E.

Please continue to next page
Form 3-200-54

Rev.October 2010

Page 13 of 14

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. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently
valid OMB control number.

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 Enhancement of Survival permit 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)].

Form 3-200-54

Rev.October 2010

Page 14 of 14