Form 3-200-37 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/TAKE OF ANIMALS
(LIVE/ SAMPLES/PARTS/PRODUCTS) (ESA and/or CITES)
(circle/highlight proposed activity)
 New Application
 Requesting Re-issuance/Amendment of Permit#: _____________

Complete Sections A or B, and C through H 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

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?

2.

Yes
3.

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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E. EXPORT/IMPORT/INTERSTATE AND FOREIGN COMMERCE/TAKE OF ANIMALS (Live/
samples/parts/products) (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 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 (Indicate appropriate activities):
EXPORT IMPORT INTERSTATE COMMERCE* FOREIGN COMMERCE TAKE
*Interstate Commerce permits authorize the sale of endangered and threatened species across State lines, but
only for activities that will contribute to enhancing the propagation or survival of that species. Captivebreeding alone will not generally meet this requirement. Scientific research must be related to the species to
be permitted. Interstate commerce activities with wildlife require the buyer to obtain a permit prior to the sale.

2.

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

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

b.
Description (e.g., birth date; sex, if known; and identifying features, if any, such as tattoo, identification
number, microchip number and location of microchip1, or scars; if biological samples, size of sample, total
amount or number of samples, and size/type of container):

3.

The current location of the specimen(s) (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.
________________________________________________________________________________
________________________________________________________________________________

F. SOURCE OF SPECIMEN (answer question 5 or 6 for each specimen involved, as appropriate).
5.

For each specimen born in captivity:
a.
If you are the breeder of the specimen(s), please provide a signed and dated statement that includes the
following:
i.
That each animal was bred and born at your facility;
ii.
Scientific name (genus, species, and, if applicable, subspecies) and common name;
iii. Birth/hatch date, and, if applicable, identification information (as described in question 2b above);
iv. Name and address of your facility where each animal was bred and born; and
v.
Location (Name of facility, address, city, State/province, postal code) of parental stock.

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b.

6.

If you are NOT the breeder of the specimen(s), provide 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) and a signed and dated statement from the breeder or
breeder's record that clearly includes the following:
i.
That each animal was bred and born/hatched at his/her facility;
ii.
Scientific name (genus, species, and, if applicable, subspecies) and common name;
iii. Birth/hatch date, and, if applicable, identification information (as described in question 2b above);
iv. Name and address of the breeder’s facility; and
v.
Location (name of facility, address, city, State/province, postal code) of parental stock.
For each specimen taken from the wild, provide the following (please use a separate sheet of paper):
a.
Scientific name (genus, species, and, if applicable, subspecies) and common name;
b.
Specific location of where, when, and by whom (name and address) the specimen was removed from the
wild;
c.
Purpose of removal and length or approximate length of time held in captivity;
d.
Describe your efforts to use captive specimens (e.g., captive-born, captive-held), or parts thereof, in lieu
of taking animals from the wild.
e.
Copies of your foreign or domestic collecting permit, license, contract or agreement;
f.
Documentation showing that the specimen(s) was legally obtained by the applicant; and
g.
Copies of any applicable State permits or licenses that are required to house, maintain, breed, and/or sell
these specimens (contact your State for information).

G. JUSTIFICATION FOR REQUESTED ACTIVITY.
7.

Provide a full statement justifying the permit including details of the activities, particularly the following
(please 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. If the
proposed activity involves the import of live animals, include the experience of each animal caretaker
working with the species.
c.
Copies of contracts, agreements or other documents that identify persons involved and dates of activities
for which authorization is being requested.
d.
A statement on how the activities will enhance or benefit the wild population (in-situ and ex-situ
projects). If your activities include conservation education, provide copies of educational materials (e.g.,
handouts, text of signage or public presentations). Educational material must discuss the ecological role
and conservation needs for the species involved in the proposed activity.

8.

If live specimens are to be held in captivity as part of the proposed activity:
a.
Provide a detailed description (e.g., size, construction materials, protection from the elements) and
photographs or diagrams (no blueprints, please) clearly depicting the existing facilities where the
wildlife will be maintained. If the specimens will be housed at multiple facilities, either immediately or
within the next year, provide a full description of each facility. If you are unsure of which facilities may
be receiving specimens (e.g., SSP has not made final decision), please indicate likely candidates and the
mechanism that will be used to determine recipient facilities.
b.
A statement of the specific technical experience available to the recipient(s) for maintaining and
propagating live specimens of the same or similar species, including:
i.
The number of years each species has been maintained;
ii.
A list of the number of successful births by year for each species for the last 5 years; and
iii. Mortalities resulting from your activities with these or similar species in the last 5 years, causes of
such mortalities, and steps taken to avoid or decrease such mortalities.

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H. IMPORTS, EXPORTS, OR RE-EXPORTS.
9.

If importing or exporting specimens:
a.
Provide a copy of any required foreign permits (for CITES Appendix-I specimens provide a copy of
import permit or evidence one will be issued).
b.
The transport conditions for live animals 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:
i.
The type, size, and construction of any shipping container; and
ii.
The arrangements for watering or otherwise caring for the wildlife during transport.
c.
For import of live CITES Appendix I listed marine mammal specimens, provide a copy of your
FWS or NOAA Fisheries permit or authorization.

10.

For import of CITES Appendix I listed species provide information to show the import is not for primarily
commercial purposes as outlined in Resolution Conf. 5.10 (www.cites.org).

11.

For export of Appendix I listed species provide a copy of the CITES import permit, or evidence one will be
issued by the Management Authority of the country to which you plan to export the specimen(s). In
accordance with Article III of the CITES treaty, it is required that import permits are issued before the
corresponding export permit.

12.

If the specimen is being re-exported (exporting a specimen that was previously imported into the United
States) provide:
a.
A copy of the canceled CITES export or re-export document issued by the appropriate CITES office in
the country from which the wildlife was imported (if applicable); and
b.
A cleared copy of Form 3-177, wildlife Declaration for Import (hard copy or electronic release); or
c.
If you did not make the original import, provide a copy of the importer's documents outlined above and
the invoice or other documentation that shows you acquired the wildlife from the original importer or
history of transactions which demonstrate chain of ownership.

13.

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 from http://www.fws.gov/le/ImpExp/Contact_Info_Ports.htm.)

14.

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

15.

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:
__________________________________________________________________________

16.

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 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, through H. .
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 90 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, or tribe, 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 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 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/Take of Animals application is 2 hours. 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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