Form 3-200-29 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:

Export/Re-Export of Wildlife Samples and/or Biomedical
Samples (CITES)
(Circle or highlight your requested activity)

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

C.

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact

7.b. Alternate telephone number

Applicant address

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 identified on page 2. 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)

Form 3-200-29

Rev. <>

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E. Export/Re-Export of Wildlife Samples and/or Biomedical Samples (CITES)
For the export/re-export of samples from species listed under the Endangered Species Act or CITES Appendix I
species (50 CFR Part 17), use application form 3-200-37 [www.fws.gov/forms].
Note: For permits that qualify to be issued by the Office of Law Enforcement, the applications must be
submitted to the Law Enforcement office within the region you reside.
Note: the U.S. FWS may not be able to issue CITES documents for the commercial export of Appendix-I
specimens, unless the specimens were obtained from animals produced at a CITES-registered Appendix-I
commercial breeding operation. For more information on registering an Appendix-I commercial breeding
operation, contact the Division of Management Authority at 800-358-2104 or [email protected].
Electronic submission of inventories, photographs, and receipts: Some applications contain extensive
inventories and/or a large number of photographs or receipts. You may provide electronic versions of these
documents. Such a submission may assist in expediting the processing of your application since it may reduce
data entry by the U.S. Fish and Wildlife Service. You may include a disk containing your information or check
here  if you would like to be contacted to provide it via email.
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 you are applying for multiple specimens,
be sure to indicate which specimen you are addressing in each response.
1. What activity are you requesting authorization to carry out?
1aSINGLE SHIPMENT for export (Processing Fee = $100)
(Choose what type of shipment and fill in foreign recipient address)
1b SINGLE SHIPMENT for re-export only (Processing Fee = $75)
1c ESTABLISHING A MASTER FILE (Processing Fee = $200)
(This application allows you set up a Master File, valid for three years and is renewable, for exports of
specimens under CITES. Once the Master File is approved you would need to obtain single-use permits,
valid for 6 months, for each export (50 CFR 13.11))
1d.RENEWAL OF AN ESTABLISH MASTER FILE, # ___________________ (Processing Fee = $100)
IF establishing a new master file or renewing a previous master file,
How many single-use permits do you anticipate using in the next 6 months? ____________________
(Provide $5 for each 6-month permit.) Additional permits may be requested by submitting form 3-200-74
(http://www.fws.gov/forms/).
2. Provide recipient’s foreign address: _________________________________________________________
________________________________________________________________________________________
3. Are you requesting authorization to export, or re-export specimens? _________________________

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4. For EACH animal from which samples are to be shipped, provide the following (You may use the attached
corresponding inventory sheet): Please do NOT include Quarantine, Immunization or Health records
unless they document transfer of ownership. (See sample inventory page provided.)
a. Scientific name (genus, species, and, if applicable, subspecies);
b. Common name;
c. Animal's Identification number or House name;
d. Sex, if known;
e. Birth/hatch date or age class;
f. Source of specimen (Wild or Captive-Born);
g. If this is a re-export, Foreign CITES export permit number issuance date;
h. Type of sample (e.g., blood samples, cell cultures, tissue samples); and
i. Quantity of samples & how packaged (e.g., 10 1-ml flasks, paraffin blocks, slides).
5. What is the purpose of the export? ___________________________________________________
6. Where is/are the specimen(s) currently located? _______________________________________________
7. For wildlife previously imported into the United States from another country (Re-export), provide:
a. Copies of canceled CITES export or re-export documents issued by the appropriate CITES office in the
country from which the wildlife was exported, and
b. Copy of cleared wildlife Declaration for Import (Form 3-177); or
c. Copies of Inventory sheets that accompanied the original shipment showing original tattoo#’s.
d.

If you did not make the original import, provide copies of the importer's documents outlined above and the
invoices or other documents that shows you acquired the wildlife from the original importer or history of
transactions (chain of ownership).

8. For samples collected from animals born in the wild, provide: (either in the U.S. or in another country)
a. Specific location of where, when and by whom (name and address) the animal/sample was removed from the
wild;
b. A description of the method(s) of collection, including previous results using this methodology (e.g. mortality
rate, adverse impacts);
c. The qualifications of the individuals collecting the samples;
d. A copy of any applicable State, Federal, or foreign government authorization approving the activity; and
e. Documentation that the applicant legally acquired the animals/samples.
f. In addition, For wild-born animals currently or previously held in captivity, describe the purpose of
removing the animal from the wild, length or approximate length of time the animal was or will be held in
captivity, and, if still in captivity, current location (including a history of where the animal has been maintained
in captivity).
9. For samples collected from animals born in captivity within the United States:
a. Have the specimens been collected? If not, when will they be collected?
b. If you are the breeder, please provide a statement that the animal was bred and born at your facility. This
statement must include:
i. Scientific name, birth/hatch date, sex, and, if applicable, band/tag number or other identifier of each
specimen;
ii. Name and address of your facility where the animal was bred and born;
iii. Location (Name of holder, city, State, zip code) of parental stock;
iv. Whether the parental stock was captive-born or wild-collected; and
v. Your signature and date.

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c. If you are NOT the breeder of the specimen, provide a signed statement from the breeder or breeder's record
that includes: (signed by the attending Veterinarian in charge of the colony.)
i. Scientific name; birth/hatch date, sex, and, if applicable, band/tag number or other identifier of each
specimen he/she bred;
ii. Complete name and address of the breeder's facility;
iii. Statement that the animal was bred and born at the breeder’s facility;
iv. Location (name of holder, city, State, zip code) of parental stock; and
v. Whether the parental stock was captive-born or wild-caught.
vi. In addition, copies of documentation showing that you acquired the animal from the breeder or
documentation demonstrating the history of transactions (chain of ownership of each animal).
10. For marine mammals samples, provide a copy of your FWS or NOAA Fisheries permit or authorization.
11. 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 _________________

12. 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 from 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 an 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):
______________________________________________________________________________________
If you are the taxidermist or broker, 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.

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Please do not submit handwritten inventories with your application. You may re-create this spreadsheet as long as it contains all the necessary information.

Export/Re-export of Wildlife Samples (CITES)
Inventory Page
a. Scientific
Name
(genus, species,
subspecies)

b. Common
Name

c. Animal
Number or
House
Name

d.
Sex

e. Source
(Wild or
CaptiveBorn)

f. Birth Date
/ Age Class

g. CITES

h.

Export Permit
No.

Export
Permit
Issuance
Date

i. Type of
Sample
(blood, tissue,
DNA)

j. Quantity of
samples & how
Packaged
(vials, slides,
flask)/size and No.
of samples

If Re-export
EXAMPLE:
Macaca
fascicularis

Enter column
totals for total
no. animals,
total mls, and
total vials/
flasks/ slides,
etc:

3-200-29

Crab-eating
macaque

RX7272-09

F

W

5/6/1992

VN0101-1998

07/05/98

TOTAL VAILS=
TOTAL ML=

Page 5 of 7

Liver cells

20 1-ml vials
containing 0.5 mls
each

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, 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, or tribe 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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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), 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 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/Export/Re-Export of Trophies of Wildlife Samples and/or Biomedical Samples application is 2 hours 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 nonconfidential 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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