Form 3-200-49 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:

Approval, Amendment or Renewal of
a Cooperative Breeding Program
(Wild Bird Conservation Act)

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

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact

7.a. Business telephone number

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 indicated on page 2. 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?
Yes
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: _________________________________No

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)

Please continue to next page

Form 3-200-49

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E. Approval, Amendment or Renewal of a Cooperative Breeding Program (Wild Bird Conservation Act)
This application must be approved before import permits can be issued for the purpose of cooperative breeding. A
Cooperative Breeding Program (CBP) must have at least two members. Zoological institutions may be members of
a CBP. Once a program is approved, you must submit application form 3-200-48 to request import authorization
for specific birds.
The lead cooperator for the breeding program should submit this application.
Provide the following information and complete all relevant questions on the application. Mark questions that are
not applicable with "N/A". Please use a separate sheet of paper to answer the application questions. On all
attachments or separate sheets you are submitting, please indicate the number of the application question you are
addressing. If requesting authorization for more than one species or subspecies, please answer questions 2 – 5 for
each species/subspecies.
1.

Are you requesting to:
 Establish a new cooperative breeding program
PROCESSING FEE = $200
(Please answer all questions)
 Amend an existing cooperative breeding program; CBP# __________
PROCESSING FEE = $100
(If requesting new species, answers questions 1 and 2, and questions 6 through 8)
 Renew an existing cooperative breeding program; CBP#___________
PROCESSING FEE = $50
(If there are no changes to the membership or species in the CBP, please answer questions 6 through 8)

2. A description of the species/subspecies to be covered (imported) under the program, including:
a. Scientific name (genus, species, and, if applicable, subspecies) and common name;
b. Number of birds required to meet the goals of the program (Note: indicate the total number of birds to be
imported by all the members of the CBP for the life of the program); and
c. Desired sex ratio.
3. A statement justifying the need for this approval, which includes information on the current U.S. captive
population of the requested species/subspecies and the need for import of additional specimens. Also, provide a
description of the cooperative breeding program that includes:
a. Breeding protocol, including a genetic management plan and breeding methods, that justifies the total
number of birds to be imported by the CBP;
b. Description of the long-term plans for developing and maintaining a self-sustaining population in captivity
of the exotic bird species;
c. Details on the system of record keeping and tracking of birds and their offspring, including how individual
specimens will be marked or otherwise identified;
d. Explanation on the relationship of the cooperative breeding program to the conservation of the exotic bird
species in the wild;
e. Information on the long-term funding of the cooperative breeding program to ensure its existence until the
CPB’s breeding goals are met; and
f. Detailed plans for the placement of the exotic birds and any offspring, recalling that birds imported as
part of a cooperative breeding program cannot be loaned, sold or otherwise transferred to a nonmember without prior authorization of this office. Also, provide a description of how program birds will
be dealt with if a member(s) leaves the program or if the program is voluntary terminated (members decide
to disband and the program is not renewed) or involuntary terminated (the Service does not renew the CBP).

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4. Describe care and maintenance of the requested species/subspecies, and how each prospective member’s
facilities meet professionally recognized standards, including:
a. Name and addresses of each facility where the birds will be maintained;
b. Photos and/or detailed description of each facility, including dimensions of enclosures for the birds to be
imported and offspring and the number of birds to be housed in each;
c. Husbandry practices; and
d. A qualification statement for EACH individual who will be participating in CBP. This statement should
include records showing the participant's prior breeding experience with bird species that are the same or
similar to the species in the CBP.
5. Each CBP must identify an appropriate avicultural, zoological, or conservation organization that has agreed to
oversee its activities. Please provide a statement from the designated oversight organization, on the
organization’s letterhead, that includes at a minimum:
a. Description of the expertise of the organization to serve as an oversight organization;
b. Criteria for acceptance of individuals into the proposed breeding program;
c. How participation in the program will be monitored; and
d. Relationship of the oversight organization to the CBP in establishing and maintaining a self-sustaining
captive population of the exotic bird species or enhancing the conservation of the species in the wild.
6. If you are amending or renewing a program, you must also provide the following information:
a. The number, species, and sex of all birds that have been imported to date for your CBP, including dates of
import, countries of origin, and disposition of the imported birds for each importer;
b. For each program participant, a summary of any breeding activity that has been achieved with the imported
birds, including the number of eggs and progeny produced, and the disposition of any progeny;
c. For each program participant, a summary of any mortality, including mortality during transit or quarantine
(for birds that died in quarantine, you must provide appropriate documentation from USDA/Veterinary
Services) of birds imported as part of the approved cooperative breeding program, as well as details of any
post-fledging mortality of their progeny;
d. A summary of progress made towards achieving a self-sustaining captive population of each species;
e. An explanation of any substantive changes that have or will occur regarding any aspect of the approved
cooperative breeding program; and
f. An official letterhead statement from the designated oversight organization approving the amendment or
renewal.
7. Provide a signed statement from each CBP member. The statements must contain the following information:
a. Member name;
b. Scientific name of all species being requested for the program;
c. Statement that the member is aware of the purposes of the cooperative breeding program and the Wild Bird
Conservation Act and will abide by the regulations and conditions placed on the program, if it is approved.
8. Provide the address where you want permit mailed (if different than page 1).
9. 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.
Note: If we have questions, we will contact the lead cooperator identified in block A. on page 1.

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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 ,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 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 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 Approval, Amendment or Renewal of a Cooperative Breeding Program application is 3 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
non-confidential 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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