Form 3-200-40 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
Type of Activity:

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

EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS
(U.S. Endangered Species Act)
 New Application
 Requesting Renewal/Amendment of Permit# ____________

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?
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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Please continue to next page

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E.

EXPORT AND RE-IMPORT OF MUSEUM SPECIMENS (U.S. Endangered Species Act)
An ESA museum permit only authorizes export and re-import of preserved, frozen, dried, or
embedded specimens or herbarium specimens currently accessioned in your museum. If
specimens are protected by CITES, Marine Mammal Protection Act, Migratory Bird Treaty Act, or
Bald and Golden Eagle Protection Act (that are not pre-Act), you would be required to obtain
additional authorizations prior to any export or re-import of specimens. Contact DMA for the
required application.
Note: For the import or export of specimens that are not part of your museum collection or have not
yet been collected, please submit form 3-200-37.
For renewals, include the original Certificate and the annual report. The report is a summary of all
exports and re-imports conducted under your permit for the past year, including scientific name and
common name of specimen sent or received, date of activity, acquisition number, description,
receiving/sending institution, and country.

ENTER an "X" in the box that applies.
1.
YES
NO
Are you an accredited scientific institution? If yes, with whom are you
accredited? ____________________________________________________________
2.

YES
NO
professionally curated?

3.

As appropriate, ENTER approximate number of accessioned specimens:
_______ Mammals
_______ Birds
_______ Insects/Arachnids
_______ Other Invertebrates
_______ Reptiles/Amphibians
_______ Vascular Plants
_______ Fish
_______ Other (specify)

4.

YES
NO
Do you maintain any specimens protected under the Marine Mammal
Protection Act? If "yes," do you wish to export and re-import these specimens?
______________________________________________________________________________
If yes, provide a copy of your MMPA authorization for this activity.

5.

YES
NO
Do you maintain any specimens protected under the Migratory Bird
Treaty Act? If "yes," do you wish to export and re-import these specimens?
_____________________________________________________________________________
If yes, provide a copy of your MBTA authorization for this activity.

6.

YES
NO.
Do you maintain any specimens protected under the Convention on
International Trade of Endangered Species of Wild Fauna and Flora (CITES)? If "yes," do you wish
to export and re-import these specimens? _________________________________________
If yes, provide a copy of your CITES authorization for this activity.

7.

YES
NO
Do you maintain any specimens protected under the Bald and Golden
Eagle Protection Act? If "yes," do you wish to export and re-import these specimens? ________
If yes, provide a copy of your BGEPA authorization for this activity.

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Are your collections and associated data permanently housed and

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8.

YES
institution?

NO

Are specimens accessible to qualified users from outside your

ENTER approximate number:
Loans last year:
Exchanges last year:
Donations last year:
9.

YES

NO

In the United States
________________
________________
________________

Outside the United States
____________________
____________________
____________________

Are all accessions properly recorded in a permanent catalogue?

10.

YES
NO
transferred?

Are permanent records maintained on specimens that are loaned or

11.

YES
results of

NO

Are specimens acquired primarily for the purpose of research, the
which are to be reported in scientific publications?

12.

YES

NO

Are specimens prepared and the collections arranged in a manner that
ensures their availability?

13.

YES

NO

Are data on specimen labels, permanent catalogues, and other records as
accurate as possible?

14.

Yes
NO
To the best of your knowledge, were the specimens in your collection
acquired legally under the relevant laws of the country where they were obtained and the United
States (e.g., import permits, collection permits, take permits, land owner permission)?

15.

YES
NO
Are all specimens of endangered and threatened species permanently
and centrally housed under direct control of the scientific institution?

16.

 YES
NO
Are specimens of endangered and threatened species intended for
exchange managed in such a manner to preclude their use solely as decorations or trophies, or for
other purposes incompatible with the principles of U.S. Endangered Species Act?

17.

Please ATTACH a statement of how the activities carried out by your institution will enhance or
benefit the endangered or threatened species intended for exchange (e.g., identify recovery tasks
from the recovery plan, or describe how the research activities will benefit the species under the
Act).

18.

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

19.

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: ________________________________________________

20.

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’s 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 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 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.

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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 Export and Re-import of Museum Specimens 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)].

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