Form 3-200-80 Federal Fish and Wildlife Permit Application Form

Department of the Interior
U.S. Fish and Wildlife Service

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

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: Export of Fertilized Live Eggs, Caviar or Meat from

Aquacultured Paddlefish or Sturgeon (CITES)

If Renewal; permit no. ______________________

Complete Sections A or B, 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

C.

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact
7.b. Alternate telephone number

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

Applicant address

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

D.
1.
2.
3.

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete
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
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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Form 3-200-80

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E.

Export of Fertilized Live Eggs, Caviar or Meat from Aquacultured Paddlefish or Sturgeon (CITES)

NOTE: To request export of species listed under the U.S. Endangered Species Act, submit form 3-200-37.
Please provide the following information. If necessary, use a separate sheet of paper. On all attachments or additional pages,
please indicate the application question number you are addressing. Please do not use staples.
1.

Do you need authorization for a single shipment or multiple shipments (i.e., shipments to a cruise ship)?
Single Shipment = $100
processing fee
Provide Name and address of
recipient:

Multiple shipments = $200 processing fee

Renewal = $100

A. This application allows you set up a Master File, valid for a maximum of
up to three years, for exports of specific amounts of caviar. Once the Master
File is approved you would need to obtain single-use permits, valid for 6
months, for each export (50 CFR 13.11, see attached).
B. How many single-use permits do you anticipate using in the next 6
months upon completion of this Master File review? _________. (Provide $5
for each 6-month permit).

2.

For each species from which product will be exported, provide:
a.
Scientific name (genus, species, and if applicable, subspecies) and common name of the fish.
b.
State(s) of source specimens.
c.
Address where the facilities are located.
c.
Product description (fertilized live eggs, caviar or meat).
d.
Weight to be exported (metric units):
e.
Shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units).
f.
Shipment will be fresh, frozen, or pasteurized (circle one), or other (describe).
g.
Current location of specimen(s).

3.

For each facility, provide:
a.
Address.
b.
Photos and a description.
c.
Number of years the facility has maintained the requested species.
d.
Provide a copy of the appropriate state license(s) for the facility.

4.

Provide responses to the following regarding your production estimates in tabular form:
a.
Documentation showing the number of brood stock spawned annually;
b.
Estimated weight of eggs produced annually;
c.
Total caviar harvested annually (by weight);
d.
Total caviar sold domestically (by weight);
e.
Total caviar sold internationally (by weight);
f.
Total caviar wastage (by weight);
g.
Estimated number of fry produced annually;
h.
Average growth rate achieved at the facility;
i.
Biomass, by age class and sex, at the beginning of the year; remaining biomass, by age class and sex, at the end of the
year;
j.
Total live stock sold by age class and sex;
k.
Total meat production;
l.
Total meat sold domestically by sex (live weight is acceptable);
m. Total meat sold internationally by sex (live weight is acceptable);
n.
Mortality rates by age class;
o.
Information regarding disease outbreaks, this information should include the causative agent, if known, percent
mortality, and relevant pathological findings;
p.
Sacrifice rates by age class and sex;

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5.

Provide documentation showing how your captive population is being managed to maintain its genetic vitality (also see
questions below).

6.

Do you supplement from the wild?

7.

If you answered yes to the above question,
a.
Provide a copy of the state authorization or collection permit(s) (i.e., aquaculture permit, broodstock permits,
and capture logs.
b.
What is done with the wild-origin males or females once they have been used to improve the genetics of your farmraised population?
c.
When is the last time you used wild-origin fish?
d.
What was done with the wild-origin fish once they were used?
e.
Provide documentation which demonstrates that the wild-origin fish have no contact with the farm-raised fish.
f.
When do you next intend to use wild-origin fish to improve the genetics of the population?

8.

Provide production records for the past year.

9.

Are all roe that you are exporting F2 generation or more?

10.

If you are the Breeder, sign (in ink) the following statement or see b. below:
a.
I hereby certify that the animals listed above to be exported were bred and born/hatched from parental stock at my
facility listed below.
Name and address of your facility where the animals were bred and born; __________________________
________________________________________________________________________
Current location of parental stock_____________________________________________________________
Signature and date _____________________________________________________________________

11.

If you obtained stock from another facility, provide copies of documentation showing that you acquired the specimens from
the breeder or documentation demonstrating the history of transactions (chain of ownership of each specimen) and a signed
statement from the breeder or breeder's record that includes:
a.
Scientific name of the species;
b.
that the specimen(s) was/were bred and born/hatched at his/her facility;
c.
Birth/hatch date, and if applicable band/tag number, or other identifiers,
d.
Location (Name, Street address, City, State) of Parental Stock;
e.
Complete name and address of the breeder's facility.

12.

Indicate the U.S. port that you are requesting to use. Port: ___________________________. If no port is indicated, you
must use a port designated for the export of wildlife (see enclosed).

13.

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

14.

If you wish the permit to be mailed other than by regular mail, provide air bill, pre-paid envelope, or billing information
________________________________________________________________________________.

15.

Who should we contact if we have questions about the application? (Include name, phone number, and email):
____________________________________________________________________________.

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APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an 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, 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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Form 3-200-80

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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), 50 CFR 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 a 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 of Fertilized Live Eggs, Caviar or Meat from Aquacultured Paddlefish or Sturgeon 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 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)].

Form 3-200-80

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