Form 3-200-28 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 U.S. Fish and Wildlife Service
(enter address from page 5 of application)

Type of Activity:

Export of Trophies by Hunters or Taxidermists (CITES)

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
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

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 for Export. 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: _________________________________No
Yes

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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E.

Export of Trophies by Hunters or Taxidermists (CITES)

NOTE 1: If you are the hunter exporting your personal, sport-hunted trophy with you in your
accompanying personal baggage that was harvested in Alaska, the application can be submitted to one of
the U.S. Fish and Wildlife Service offices in Alaska (see page 4 for addresses).
NOTE 2: If you are the taxidermist or freight forwarder applying on behalf of your client, you must
complete Section B of page one with your business information. As exporter of record you are
responsible for meeting the permit requirements, and providing the documentation to show you have
Power of Attorney to act on your client’s behalf. The application must be submitted to the Division of
Management Authority (see address
on page 4).
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. If applying for more than one trophy,
be sure to answer all of the questions for each trophy.
1. Provide the following for each trophy:
Scientific name
(genus, species, and, if
applicable, subspecies)

Common
name

State Tag #,
Seal Tag #,
CITES Tag #

Sex

Description: Raw or Finished
(if Finished, describe - e.g. life
size mount, skin, skull, rug)

Month and Year
Animal
Harvested

2. Provide the hunter's name (if not given above) and foreign address.
Name:
Address:
City, Country, Postal Code:
3. U.S. address (not a P.O. Box) for foreign applicant. (50 § 13.12 requires this information for
issuance).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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4. Applicants residing or located outside the United States conducting commercial activities. The
name, physical address and telephone number of your agent that is located in the United States who will
maintain your records for five (5) years from the expiration of the permit. If the location is the same as
Question 3, then indicate “same as Question 3". (50 § 13.12 and 13.46 requires this information).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Current location of trophy(ies):
_______________________________________________________________

6. What is the purpose of the export?
______________________________________________________________________________________
______________________________________________________________________________________
7. Was the trophy a native U.S. species taken in the United States? If yes, provide:
a. A copy of the State hunting license under which the specimen was taken, if required. If a copy of
the license is unavailable, provide name of hunter, license number, State of take, and date of take.
If a tag or seal is required, provide the tag/seal number.
_______________________________________________________________________________
_______________________________________________________________________________
__________
b. Location where trophy was taken (area, region, or ranch and nearest city).
_______________________________________________________________________________
_______________________________________________________________________________
__________
8. Was the trophy a non-native (i.e., exotic) species taken in the United States? If yes, provide:
a. A statement from the ranching operation or appropriate authorities of the hunting area that includes
the scientific name; common name; month, year, and place of birth of the trophy animal; the date
on which the animal was hunted; and the name of the authorized hunter. This statement must be
signed by the person in charge of the ranching operation or hunting area and include the location
where trophy was taken (area, region, or ranch and nearest city).
b. A copy of the State hunting license under which the specimen was taken, if required. If a copy of
the license is unavailable, provide name of hunter, license number, State of take, and date of take.
If a tag or seal is required, provide the tag/seal number.
7. For CITES Appendix-I species, provide a copy of the CITES import permit issued by the Management
Authority of the country to which you plan to export the wildlife (country of recipient in question 2
above).
8. Enter the U.S. port through which the export/re-export 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
prior to leaving the United States. A list of designated ports (where an inspector is posted) is available at
(http://www.fws.gov/le/ImpExp/Contact_Info_Ports.htm.)

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9. Address where you wish permit mailed (if different than page 1):
____________________________________________
_____________________________________________
______________________________________________
_____________________________________________
10.
If you wish the permit to be sent to you by means other than regular mail, provide an air bill, prepaid envelope, or billing
information:________________________________________________________________
______________________________________________________________________________________
____
11.
Who should we contact if we have questions about the application? (Include name, phone number,
and email):
_____________________________________________________________________________________
_

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CITES Permit Offices

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
Office of Law Enforcement
NOTE: Only hunters who are exporting their personal, sport-hunted trophy in their accompanying
personal baggage that was harvested in Alaska may submit the application at one of the U.S. Fish and
Wildlife Service offices listed below:
Anchorage
U.S. Fish & Wildlife Service
Office of Law Enforcement
P.O. Box 190045
4600 Postmark Drive, Suite NB207
Anchorage, Alaska 99519
Phone: (907) 271-6198
Fax: (907) 271-6199

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Fairbanks
U.S. Fish & Wildlife Service
Office of Law Enforcement
1412 Airport Way
Fairbanks, Alaska
Phone: (907) 456-2335
Fax: (907) 456-2356

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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 § 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 through 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 §
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, tribe 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:
Application processing fee:

An application processing fee is required at the time of application; unless exempted under 50 § 13.11(d)(3). 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 if no
significant processing has occurred.

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.
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.
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:

Question 3. Enter the complete U.S. address. This can be a temporary address (such as a hotel, relative, etc.). 50 § 13.12 requires this information for
issuance.

Question 4. Enter the complete name and physical address where your records (as defined in 50 § 13.46) will be maintained for five (5) years from the date
of expiration of the license. This can be a customshouse broker, relative, etc. It cannot be a retail postal or mail service center. 50 § 13.12 requires this
information for issuance.

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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 andhttp://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), 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 Export of Trophies by Hunters or Taxidermists 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)].

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