First Receiver Site License Application and Renewal

OMB Control No. 0648-XXXX, Expiration Date: mm/dd/yyyy

FIRST RECEIVER SITE

LICENSE RENEWAL FORM

PACIFIC COAST GROUNDFISH
Limited Entry Permit

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
Northwest Region , Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353
www.nwr.noaa.gov

Fax (206) 526-4461

Please make any changes as appropriate to the addresses, phone and fax number and email address listed below.
Please sign, date and return the form with payment.
License Number:
License Holder:
License Holder name(s):
Business Address:
City:
State:
Zip Code:
Business Phone:
Fax Number:
Email address:
Physical Site Location of IFQ Offload

□ Check here if address is same as given above

If different from license holder, please provide below
Business address (street address only)
City:
State:
Zip
Business Phone:
Fax Number:
Email address:
Name of Plant Contact if different from license holder:

Code:

Please sign below to certify that the above information is true, correct and complete (edit if necessary) to the
best of your knowledge and return this form with a check or money order for $XXXX made payable to U.S.
Department of Commerce, NOAA. Mail to: NOAA/NMFS/Northwest Region, Sustainable Fisheries
Division, 7600 Sand Point Way NE, Bldg. #1 Seattle, WA 98115-0070.
____________________________________________________________________________
Signature of owner(s)
Title (If corporate officer)
Date
Print Name of Signatory: __________________________
Warning Statement: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under
15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and as a federal crime under 18 USC 1001
PRIVACY ACT STATEMENT: Phone number, fax and email information are not released to the public. The permit sale/lease
information and the amount of sablefish landed to date given on a transfer form are considered confidential. Similarly, the names
associated with a entity that owns a sablefish permit or has vessel registered to sablefish endorsed permit are confidential, as are date of
birth for an individual and any medical records provided to obtain an exemption from the owner on board required. The information
collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally
Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11,
2008 (73 FR 33065).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.33 hours per response,
including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest
Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Some
of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act. It is also confidential
under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax and email information
are not released to the public.

OMB Control No. 0648-XXXX, Expires on: mm/dd/yyyy

FIRST RECEIVER SITE
LICENSE
PACIFIC COAST
GROUNDFISH

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

INSTRUCTIONS
This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address to
apply for a first receiver site license. A first receiver site license authorizes a first receiver to receive, purchase, or
take custody or control of an IFQ landing at the physical location of the facility given on the license. This license
is effective upon approval by NMFS.
Section A – First Receiver Information
The applicant must provide the name of the first receiver as given on the state buyer’s license, the state in which
the buyer’s license was issued and the buyer license number. The buyer’s license must be issued by the state in
which the receiving facility is located as given in Section B. A copy of the state buyer’s license must be included
with the application. Provide the tax identification number if the first receiver is a business entity or date of birth if
an individual. The applicant must provide the first receiver’s business address, phone number, fax number
(optional) and email address. Please provide the name of contact person if the first receiver is a business entity
and phone number if different from that given for the first receiver business entity.
Section B – Physical Location of Receiving Facility
The applicant must provide the name of the legal owner of the landing facility where the IFQ landings will occur,
the owner’s tax identification number, the physical location of the receiving facility (street address only), city, state
and zip code. The applicant must provide a phone number, fax number and email address (optional) and the
name of the receiving facility’s manager. If the first receiver intends to receive IFQ landings at multiple sites,
please append the application and provide all information requested in Section B for these receiving facilities. A
separate catch monitor plan must be provided for each unique receiving facility.
Section C - Certification of Applicant and Notary:
The applicant or authorized representative must sign and date the form in the presence of a notary to certify that
the individual(s) signing the form have satisfactorily identified themselves. By signing and dating the form, the
applicant or authorized representative certifies that all information set forth in the form is true, correct, and
complete to the best of the applicant's knowledge and belief. The form will not be considered without the
authorized representative’s signature. The notary must sign and date this section, and affix notary stamp or seal
If the applicant is business entity, the authorized representative must include a copy of the corporate
resolution or other document authorizing the individual to sign and certify on behalf of the business entity.
.
Supplemental Documentation
The applicant must provide a catch monitor plan for the site given in Section B that provides all of the
information provided in template (see attached outline).
The applicant must provide a copy of their state buyer’s license in the state where the receiving facility is
located.

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First Receiver Site License Application Form – Page X of X

OMB Control No. XXXX-XXXX, Expires on: XX/XX/XXXX

FIRST RECEIVER SITE
LICENSE APPLICATION

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070

PACIFIC COAST GROUNDFISH

Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

SECTION A – APPLICANT/FIRST RECEIVER INFORMATION
2. Buyer License #

1. State of Buyer License

3. First Receiver Name

4. TIN or DOB

6. State Registered in, if business entity

7. Business Mailing Address

8. Business Phone

(
Street or PO Box

)

9. Business Fax (optional)

(
City

State

Zip Code

First Receiver Contact Person/Name:

)

10. Business Email (optional)

Business Phone

(

)

SECTION B – RECEIVING FACILITY INFORMATION (PHYSICAL LOCATION OF IFQ LANDING)
1. Name of Owner of the Receiving Facility

TIN

2. Street Address (No P.O. box numbers)

3. City

4. State

6. Fax

(

5. Zip Code

7. Phone

)

(

8. E-mail

)

9. Plan Manager/Point of Contact at receiving facility

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First Receiver Site License Application

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SECTION C - CERTIFICATION OF APPLICANT AND NOTARY
This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.

Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed
this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Date

Signature of Authorized Representative

Printed Name of Authorized Representative (NOTE: attach authorization, if needed)

Notary Public Signature

 ATTEST

Affix Notary Stamp or Seal Here

Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil
penalty of up to $140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.
PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of
this collection. The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a
unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The
information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated
Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).
PRA STATEMENT: Public reporting burden for this collection of information is estimated to average .5 hr. per response, including the time for reviewing the
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National
Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115.
Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have
an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and
are not released to the public.

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First Receiver Site License Application

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