Form 3-200-23 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
Type of Activity:

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

Export of Pre-Convention, Pre-Act, or Antique Specimens
(CITES, MMPA and/or ESA)

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

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 $75. 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
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 3-200-23

Rev. <>

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E. Export of Pre-Convention, Pre-Act, or Antique Specimens (CITES, MMPA and/or ESA)
Description
pre-Convention

pre-Act

Antique
pre-MMPA

Applicable Date
Specimen was acquired (removed from the wild or held in captivity or a controlled environment)
before the date CITES applied to it. The listing date can be found at the CITES website
(http://www.cites.org).
Specimen was acquired or held in a controlled environment on or before (a) December 28, 1973
or the date when the species was listed, and (b) has not entered into commerce (e.g., been
bought, sold, or offered for sale by you or anyone else) since December 28, 1973, or the date
when listed.
Specimen was manufactured or removed from the wild over 100 years old ago.
Specimen was taken prior to December 21, 1972.

CITES - Convention on International Trade in Endangered Species of Wild Fauna and Flora
MMPA – Marine Mammal Protection Act
Act – Endangered Species Act (ESA)

Provide the following information. Complete all questions on the application. Mark questions that are not
applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit,
indicate the application question number you are addressing.
Note: For shipment of Brazilian rosewood (Dalbergia nigra), submit form 3-200-32 (www.fws.gov/forms).
Note: For fossilized walrus ivory removed from the wild after 1972, please use form 3-200-27
Note: Raw ivory tusks may not be re-exported. African elephant ivory removed from the wild after February 4,
1977, is not considered to be Pre-Convention; and worked African elephant ivory may only be re-exported
for non-commercial purposes. If you would like to re-export such items, submit form 3-200-73
(www.fws.gov/forms).
Electronic submission of inventories, photographs, and receipts: Some applications contain long inventories and/or
a large number of photographs or receipts. You may provide electronic versions of these documents. Such a
submission may assist to expedite the processing of your application since it will eliminate the need for data entry
by U.S. Fish and Wildlife Service. You may include a disk containing your information or  check here to be
contacted via e-mail to provide an electronic inventory.
1.

2.

For EACH specimen, please provide the following:
a.
Scientific name (genus, species and, if applicable, subspecies) and common name;
b.

Description of item (e.g., published description from a catalog or art book) and size (in metric units);

c.

Date of manufacture;

d.

Date of acquisition and corresponding documentation or other information on how the specimen was
acquired (e.g., bill of sale, U.S. Customs import declaration, transfer documents).

Provide the current location of specimen(s) (address and country):
_______________________________________________
______________________________________________________________________________________
____

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3.

What is the purpose of the export?
_______________________________________________________________________________________
___

4.

Name and address of foreign recipient.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

5.

If protected under CITES, provide documents, signed statement, or other evidence that the specimen(s) was
obtained or manufactured prior to the date CITES applied to the item (see pre-Convention definition above).

6.

For specimens(s) protected under the U.S. Endangered Species Act (ESA), provide one of the following:
a.
For Antiques (see definition above):
i.
Provide documentation which shows the age OR a statement from a qualified appraiser attesting
to the age; AND
ii.
Signed statement that the item has not been repaired or modified on or after December 28, 1973
with any part of any species protected by ESA.
b.

For the export of all other items that are less than 100 years old (see pre-Act definition above) and that
are not African elephant ivory:
Has this item entered into commerce (e.g., been bought, sold, or offered for sale by you or anyone else)
since December 28, 1973? Yes ______ No ______.
i.
If Yes, you must complete form 3-200-37 [www.fws.gov/forms].
ii.
If No, sign the below certification:

CERTIFICATION STATEMENT
I certify to the best of my knowledge and belief that this endangered or threatened wildlife was 1) held in
captivity or in a controlled environment on December 28, 1973, or the species listing date, if later, 2) that the
purposes of such holding were not contrary to the purposes of the Act, and 3) that the wildlife was not held in
the course of a commercial activity.
Applicant's signature: ________________________________________

Date: ____________________

7.

If the specimen is protected under the Marine Mammal Protection Act, provide an affidavit and supporting
documentation that the item was taken prior to December 21, 1972 as outlined in 50 CFR 18.14
(http://ecfr.gpoaccess.gov/). For cetacean (whales) and pinniped (seals and seal lions; not walrus) specimens,
provide either a copy of NOAA Fisheries letter of authorization or evidence that NOAA Fisheries has been
contacted.

8.

If Re-export provide:
a.
A copy of canceled CITES export or re-export document issued by the appropriate CITES office in the
country from which the wildlife was imported; and
b.
Cleared Wildlife Declaration for Import form 3-177, (hard copy or electronic release; not applicable for
plants).

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9.

Is this shipment a sample collection being exported for temporary exhibition or display purposes and
accompanied by a valid ATA carnet?
 NO
 YES; If available, provide ATA carnet document number
______________________

10.

For live animals, the transport conditions must comply with the CITES Guidelines for Transport of Live
Animals or, in the case of air transport, with the International Air Transport Association (IATA) live animal
regulations (contact airline for information). As such, describe:
a.
The type, size, and construction of any shipping container; and,
b.
The arrangements for watering or otherwise caring for the wildlife during transport.

11.

Have you obtained all required State, Federal, or foreign government approval(s) to conduct the activity you
propose? (Please be aware that there may be other requirements necessary to conduct this activity such as a
hunting license, import permit, or collection permit.)
Yes
(provide a copy of the approval(s))
Have applied
Not required

12.

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. A list
of designated ports (where an inspector is posted) is available at
http://www.fws.gov/le/ImpExp/Contact_Info_Ports.htm.)

13.

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

14.

If you wish the permit to be sent to you by means other than regular mail, provide air bill, pre-paid envelope,
or billing information:
_______________________________________________________________________________________

15.

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

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PERMIT 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 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://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, 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, 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 reissuance 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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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 Export of Pre-Convention, Pre-Act, or Antique Specimens application is 45 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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