Form 3-200-40a ESA Museum Permit Report

United States Department of the Interior
FISH AND WILDLIFE SERVICE
Washington, D.C. 20240

Expires XX/XX/XXXX
OMB No. 1018-0093

Dear ESA Museum Permittee:
Enclosed is your new/renewed Endangered and Threatened Species Museum Permit. Please be sure to read all
permit conditions and use the ESA Museum permit correctly. Be aware that this permit only authorizes export
and re-import of preserved, frozen, dried, or embedded wildlife specimens or herbarium specimens currently
accessioned in your museum.
Reporting Requirements. On an annual basis, permittee must provide a report (see format below) to the
Division of Management Authority which may be submitted as a spreadsheet as described in the below table.
Copies of all validated Export/Re-import Reports must also be submitted along with the annual report. If there
is no activity to report, permittee must provide a signed statement confirming that no export/re-import activities
occurred during the year being reported. If reports are not received annually, your permit may be subject to
revocation.
Outgoing Specimen Report
Date
Sent

Description of
specimen

Collection
Date

Location where
obtained

Acquisition
no.

Scientific name and
common name

Receiving
institution,
Country

Incoming Specimen Report
Date
Received

Description of
specimen

Collection
Date

Location where
obtained

Acquisition
no.

Scientific name and
common name

Sending
institution,
Country

If you have additional questions, please contact the Division of Management Authority, 4401 North
Fairfax Drive, Room 212, Arlington, Virginia 22203, phone (703) 358-2104 or fax 703 358-2281.

Form 3-200-40a

Rev. <>

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.shtml.)
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 Export and Re-import of Museum Specimens permit 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 3-200-40a

Rev. <>