Form 3-200-39a Certificate of Scientific Exchange (COSE) Special Report

United States Department of the Interior
FISH AND WILDLIFE SERVICE
Washington, D.C., 20240
Expires XX/XX/XXXX
OMB No. 1018-0093

__US________/_
CERTIFICATE OF SCIENTIFIC EXCHANGE (COSE)
SPECIAL REPORTING CONDITIONS
Permittee: _______________________________

Reporting Requirements. Annually, permittee must provide a report to USFWS, DMA, BOP, 4401 N.
Fairfax Drive, Rm. 212, Arlington, VA, 22203. This report must describe all exchanges of specimens that
occurred in the preceding calendar year and made under the registered scientific institution system [CITES
Resolution Conf. 11.15 (Rev. CoP12)]. A suggested format is described below. Non-activity must be
reported. If reports are not received annually, the CITES registration is subject to revocation.
Due Date: March 31.
Outgoing Specimen Report
Date
Sent

Description of
specimen

Accession or
Record no.

Scientific name and
common name

Receiving institution,
Country

Code No.

Originating institution,
Country

Code No.

Incoming Specimen Report
Date
Received

Description of
specimen

Accession or
Record no.

Scientific name
and common name

In addition, permittee must maintain complete and accurate records of any specimens imported or
exported under this Certificate (50 CFR 13.46). The records must be kept current and should
include the name, address, and Certificate of Scientific Exchange (COSE) number of the institution
sending or receiving specimen(s), a description of the specimen(s) exchanged, and the date the
exchange occurred. The records must be maintained for five years from the date of expiration of
the certificate. The applicant must make the records available to US FWS employees for inspection
upon request.

Form 3-200-39a

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FEDERAL FISH AND WILDLIFE PERMIT
Paperwork Reduction Act – Notice
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.), 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. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;
c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;
e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;
f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;
g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249),
http://www.cites.org/ ,
50 CFR 23;
h. General Provisions, 50 CFR 10;
i. General Permit Procedures, 50 CFR 13; and
j. Wildlife Provisions (Import/export/transport), 50 CFR 14.
2. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form.
This report is required to obtain or retain a benefit. 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. The relevant burden for the report conditioned by an issued Certificate of Scientific Exchange is 30 minutes. This
burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing
the report. You may direct comments regarding the burden estimate 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.

Form 3-200-39a

Rev. <>