Form 3-200-19 Federal Fish and Wildlife Permit Application Form

Expires XX/XX/XXXX
OMB No. 1018-0093

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:
Import of Sport-hunted Trophies of
Southern African Leopard, African Elephant, and
Namibian Southern White Rhinoceros

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, tribe, 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 of $100. 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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Form 3-200-19

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E.

IMPORT OF SPORT-HUNTED TROPHIES OF SOUTHERN AFRICAN LEOPARD, AFRICAN
ELEPHANT, AND NAMIBIAN SOUTHERN WHITE RHINOCEROS

Note 1: If you hold an import permit for a trophy/trophies that you did not use, please return the unused original
permit. If you are requesting reissuance of a permit because you have taken a trophy, but were unable to import it
prior to the expiration of the permit, please use the renewal form, (3-200-52), [www.fws.gov/forms] and return
your original permit with that form.
Note 2: The U.S. FWS has determined that a trophy consists of raw or tanned parts of a specimen taken by a
hunter during a sport hunt for personal use. It may include the bones, claws, hair, head, hide, hooves, horns, meat,
skull, teeth, tusks, or any taxidermied part, including, but not limited to, a rug or taxidermied head, shoulder, or full
mount. It does not include articles made from a trophy, such as worked, manufactured, or handicraft items for use
as clothing, curios, ornamentation, jewelry, or other utilitarian items. If you wish to import such products, please
contact the Division of Management Authority for the proper application form.
Please provide the following information. Complete all pages of the application. Mark questions that are not
applicable with "N/A". If applying for more than one trophy, be sure to answer questions 2 and 3 for each trophy.
If importing trophies from more than one country, you must submit a separate application for each shipment in
order to obtain separate import permits.
1. ENTER the quantity next to the name of the species you are applying to import (you may apply to import
specimens of more than one species provided they have been/are being hunted in the same country):
Leopard (Panthera pardus) Quantity: _____ (Limited to the import of two per calendar year)
African elephant (Loxodonta africana) Quantity: _____ (Import permit is not required for trophies harvested in
Botswana, Namibia, South Africa, or Zimbabwe). Note: once imported, ivory can not be re-exported.
Southern white rhinoceros (Ceratotherium simum simum ) Quantity: _____ (Import permit is not required for
trophies harvested in South Africa)
2. IF ANIMAL IS CURRENTLY LIVING IN THE WILD, please enter the following:
a. Country and place (area, region, or ranch AND nearest city) where wildlife is to be taken from the wild:
b. Date wildlife is to be hunted:
c. Description of the trophy and/or parts you intend to import (e.g., skin, skull, shoulder mount, life size
mount, claws, horn):
3. IF THE ANIMAL IS DEAD, please enter the following:
a. Country and place (area, region, or ranch AND nearest city) where wildlife was removed from the wild
(provide a map if possible):
b. Date wildlife was hunted:
c. Description and size of the trophy and/or parts (e.g., skin, skull, shoulder mount, life size mount, claws,
horn):
d. The current location of the trophy (address and country):

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4. Complete name and address of overseas person or business shipping the trophy to you (this name will appear
on the face of the permit). If you are applying to import a trophy from Namibia, you must provide the name
and address of the professional hunter listed on your Namibian hunting permit.
Name:__________________________________________________________________________________
Address:________________________________________________________________________________
City/Country:____________________________________________________________________________
5. Please be aware that the U.S. Fish and Wildlife Service must make a finding that your activities will enhance
or benefit wild populations of the species involved. If you have any information that could support this finding
(e.g., how the funds from license\trophy fees will be spent, what portion of the hunting fee will support
conservation), please submit such information on a separate page with your application.
CERTIFICATION STATEMENT
6.

If you are a broker or taxidermist applying on behalf of a foreign national, provide documentation to show you have a Power of
Attorney to act on your client’s behalf and sign the following statement (disregard no. 7).
I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted by my client and is being
imported only for my client's personal use (i.e., not for sale, transfer, donation, or exchange that is reasonably likely to result in
economic use, gain, or benefit). I understand that my client may only import two leopard trophies in one calendar year (if applicable).
In addition, I have advised my client that raw ivory, once imported into the United States, cannot be re-exported.

Taxidermist/Broker’s signature: ____________________________________

Date: ______________

7. If you are the hunter applying to import your own trophy, please read and sign the following statement.
I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted by me
and is being imported only for my personal use (i.e., not for sale, transfer, donation, or exchange that is
reasonably likely to result in economic use, gain, or benefit). I understand that I may only import two
leopard trophies in one calendar year (if applicable). In addition, I understand that raw ivory, once imported
into the United States, cannot be re-exported.
Applicant's signature: ____________________________________________

Date: ___________

8. Have you obtained all required local, Federal, or foreign government approval(s) to conduct the activity you
propose? (Be aware that there may be other requirements necessary to conduct this activity such as a hunting
license or collection permit.) Yes (provide a copy of the approval(s)) Have applied Not required
9. 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 during importation. A list of designated ports
(where an inspector is posted) is available from http://www.fws.gov/le/ImpExp/Contact_Info_Ports.htm.)
10.

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

11. If you wish the permit to be delivered by means other than regular mail, provide an air bill, pre-paid envelope,
or billing information:
_______________________________________________________________________________________
12. Who should we contact if we have questions about the application? (Include name, phone number, and email):
_______________________________________________________________________________________

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APPLICATION FORM INSTRUCTIONS
The following instructions pertain to an 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 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://www.fws.gov/forms/display.cfm?number1=200
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, tribe, 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 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, tribe, 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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Form 3-200-19

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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.html
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), 50 CFR 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 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 Import of Sport-hunted Trophies of Southern African Leopard, African Elephant, and Namibian Southern White Rhinoceros application is 20 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)].

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