Form 3-200-36 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/IMPORT/INTERSTATE AND FOREIGN COMMERCE
OF PLANTS (ESA and/or CITES)
(Circle/highlight proposed 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

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. 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)

3-200-36

Rev

Please continue to Section D on next page

E.

EXPORT/IMPORT/INTERSTATE AND FOREIGN COMMERCE OF PLANTS (ESA
and/or CITES)
Allow at least 90 days for the application to be processed. Applications for endangered species
permits must be published in the Federal Register for a 30-day public comment period.
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 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.
Note: If you are requesting to export CITES-listed species, you may be required to complete
Section E of form 3-200-33.

1.

What activity are you requesting authorization to carry out? (Indicate appropriate activities):
 EXPORT

2.

3.

 IMPORT

 INTERSTATE COMMERCE

 FOREIGN COMMERCE

For EACH plant involved in the proposed activity provide:
a.

Scientific name (genus, species, and, if applicable, subspecies) and common name:

b.

Description (e.g., whole plant, cuttings, parts, products; size, height, length);

c.

Quantity;

d.

Source of specimen (wild or artificially propagated).

The current location of the specimens (address and country): ______________________________
________________________________________________________________________________

4.

Recipient/Sender:

If export, provide name and address of the recipient in the foreign country.

If import, provide name and address of the exporter in the foreign country.

If interstate or foreign commerce, provide name and address of recipient.
___________________________________________________________________________
___________________________________________________________________________

5.

What is the purpose of the export?
_____________________________________________________________

3-200-36

Page 2 of 6

F. SOURCE OF SPECIMEN (answer question 6 or 7 for each specimen involved, as appropriate):
6.

For plants taken from the wild, provide on a separate page the following for each species collected:
a.
Number of specimens collected;
b.
Specific location, and date of collection for each specimen;
c.
Who (name and address) collected the specimens;
d.
Copies of documents that indicates that the plants were legally collected (e.g., State permits or
licenses, landowner's permission). Be sure to correlate each document to the corresponding
plant;
e.
Approximate density (such as number of plants per acre) and distribution of the species at the
collection site(s);
f.
Collection methodology (e.g., whether the specimens were removed from one clump in an area
of several clumps or from more than one clump or patch at a specific location); AND
g.
Ratio of how many collected to how many remain.
h.
What efforts have you made to utilize artificially propagated specimens in lieu of taking plants
from the wild?
i.
If you purchased the plants/seeds, provide the invoice or other document that shows the name,
address and telephone number of the person from whom you purchased the plants and the date
of purchase for each specimen (such documentation should trace back to the original
collector).

7.

For artificially propagated plants, provide:
a.
A signed statement from the propagator, sworn affidavit, or other evidence that the specimen
was artificially propagated. If you are the propagator, the signed statement must by from you.
If the species are CITES-listed, do you have a valid Certificate of Artificially Propagated
Plants (CAPP)?  NO  YES, permit # ____________

8.

b.

If a specimen was not artificially propagated at your facility, provide the invoice or other
document that shows the name, address and telephone number of the person from whom you
purchased the plant and date of purchase. If the specimen was not directly obtained from the
propagator, document the history of transactions. If the species are CITES-listed, did the
propagator have a valid CAPP?  NO  YES, permit # __________

c.

If the species is CITES-listed and you either purchased the plants from a propagator that is not
currently holding a valid CAPP or you, as the propagator, do not currently hold a valid CAPP,
you will need to provide sufficient information to determine if the specimens meet the criteria
under Resolution Conf. 11.11 (rev. CoP13) to qualify as Artificially Propagated under CITES.
You may either contact our office or refer to Section E, Parts I, II, and III, of application form
3-200-33 (www.fws.gov/forms).

Provide a full statement justifying the permit including the details of the activities that includes the
following (use a separate sheet of paper):
a.
Description of the purpose of your proposed activity. If your purpose is for scientific research,
attach a copy of your research proposal which outlines the purpose, objectives, methods (e.g.,
specific information on survey/collection methods, sampling regime, equipment to be used),
and whether similar work has already been done or is currently being done.
b.
Description of the technical expertise of each person as it relates to the proposed activities.
c.
Copies of contracts or agreements or other permits that identify persons involved and dates of
activities for which the permit is sought.

3-200-36

Page 3 of 6

d.

e.

A statement on how the activities will enhance or benefit the wild population (in-situ and exsitu projects). If your activities include conservation education, provide copies of educational
materials (e.g., handouts, text of signage or public presentations). Educational material must
discusses the ecological role and conservation needs for the species involved in the proposed
activity.
Does the requested activity involve native species? If yes, provide information to show that
the activity is consistent with any recovery plan for the species.

9.

If the live plants to be covered by permit are to be propagated or maintained at your facility, provide
on a separate sheet of paper:
a.
Approximate number of specimens you currently maintain.
b.
Description of your method of propagation (e.g., seed, cutting, mericlone), and provide
photographs of your facilities, and a description of the conditions under which your plants are
grown.
c.
A description of your background and expertise in working with this or similar species,
including (i) the number of years each species has been maintained and (ii) a list of the
numbers successfully propagated annually.
d.
Provide a copy of your State license and U.S. Department of Agriculture General permit, as
appropriate.

10.

Provide a statement of whether you are willing to cooperate in a propagation program and maintain
or contribute data regarding propagation success.

11. If import or export provide:
a.
Copy of any foreign permits (for CITES Appendix-I plants provide a copy of import permit or
evidence one will be issued). If plant is to be taken from the wild, provide documentation
from the foreign government approving the action.
b.
For CITES species, describe: (i) the type, size, and construction of shipping containers and
(ii) the arrangements for watering and caring for the specimens during transportation.
c.
For import of CITES Appendix-I specimens, provide information to show the import is not for
primarily commercial purposes as outlined in CITES Resolution Conf. 5.10
(http://www.cites.org/eng/res/index.shtml).
d.
A statement on the Final Disposition of the imported plants, plant material, or progeny, if
produced. Please recognize that the plants can not be used for primarily commercial purposes
as outlined in Resolution Conf. 5.10 (www.cites.org).
12.

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

13.

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:
_____________________________________________________________________________

14.

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

3-200-36

Page 4 of 6

PERMIT APPLICATION FORM INSTRUCTIONS
The following instructions pertain to an application for a U.S. Fish and Wildlife Service or CITES permit. The General Permit
Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates are
referred to as a permit.
GENERAL INSTRUCTIONS:

Complete all blocks/lines/questions in Sections A or B, and 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 U.S. FWS programs which use foreign addresses and are not required by DMA..

Mailing address is address where communications from U.S. FWS 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 CFR 13.11(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.

3-200-36

Page 5 of 6

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 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/Import/Interstate and Foreign Commerce of Plants application is 60 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)].

3-200-36

Page 6 of 6