Form 3-200-41a Captive-Bred Wildlife Registration Annual Report

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

Captive-Bred Wildlife Registration Annual Report for Calendar Year ________
(due by March 31 of following year)
This information includes activities of all animals at your facility even if they are on loan. Note: Attach a year-end inventory of all species listed on your registration (quantity
and sex). This form may be copied. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form. Additional information may be
attached to the report.
Permittee __________________________________________ Permit number________________ Address (If location/address has changed since last year, indicate new location and
date of change):
Type Of
1
Activity
Example:
Loan out

Date Of
Activity2
4/12/02

Quantity
Sex3
(M/F/?)
1.0

Scientific Name

4

Elephas maximus

Common Name

Asian elephant

Permit No./Name/Complete
5
Address

Comments

San Diego Wild Animal Park

Id no. XXXXXXXX

MAIL YOUR REPORT TO: CBW Annual Report, USFWS, Division of Management Authority, 4401 N. Fairfax Drive, Rm. 700, Arlington, Virginia 22203
1 Type of activity: Births (if survived more than 30 days), deaths (include causes and for euthanasia, include reason for euthanasia in comment column) at your facilities, and then list other types of activities
(purchase, sale, loan, donation, gift, trade, export).
2 Date of activity is date it occurred, not necessarily the date specimen was born or transferred.
3 Sex (1.0 = Male; 0.1=female; 0.0.1 = Unknown sex).
4 Include only non-native species listed as Endangered or Threatened under the U.S. Endangered Species Act.
5 CBW Registration number and/or name and address of other CBW registrant involved in the transaction.
FWS Form 3-200-41a, REV 11/10

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

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.
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.

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 Captive-Bred Wildlife Registration is 30 minutes. This burden estimate includes time for completing 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.