Annual dealer permit application form

OMB No. 0648-0205 Form Approval Expires: 10/31/2006

U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS BRANCH, F/SER1

FEDERAL PERMIT APPLICATION FOR AN
ANNUAL DEALER PERMIT

263 13th Avenue South
St. Petersburg, FL 33701
727/824-5326 (8:00 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

FOR OFFICE USE ONLY
Reviewer's Initials and Date
Check or Money Order Number
Violation Date
Violation Clear Date
Application ID
Expiration Date(s)

FOR OFFICE USE ONLY

1. DEALER INFORMATION
INDIVIDUAL or SOLE PROPRIETORSHIP

Dealer entity is (check one):

PARTNERSHIP

CORPORATION

OTHER ____________

If the dealer is a partnership, corporation, or other business entity provide the business name, Federal Tax ID number, and date the business was filed.
Name of Partnership, Corporation, or Business

Date business was filed

Federal Tax ID Number

If the dealer is an Individual or Sole Proprietorship complete the following name, Social Security Number (SSN), and date of birth information:
Mr/Mrs/Ms

Last Name

Social Security Number

First Name

Middle Name

Suffix Name

Date of Birth

2. DEALER CONTACT INFORMATION

Mailing Address

Apt/Suite #

City

State County

Zip Code

Country

Physical Address

Apt/Suite #

City

State County

Zip Code

Country

Check box if same as Mailing Address

Area Code

Page 1

Phone Number

Form Revision 05/31/2006

3. Permits
INSTRUCTIONS: Indicate which permit(s) and transaction(s) you are applying for. Find the fishery in the left column and mark the check box beside
that fishery to indicate what transaction you want.
New

Renewal

Duplicate

New

Atlantic Dolphin/ Wahoo (DDW)

South Atlantic Wreckfish (WD)

Shark (SK)

South Atlantic Rock Shrimp (RS)

Domestic Swordfish (SD)

South Atlantic Golden Crab (GC)

South Atlantic Snapper-Grouper
Excluding Wreckfish (SG)

Gulf of Mexico Reef Fish (RD)

Renewal

Duplicate

4. COMPANY OFFICER and SHAREHOLDER INFORMATION
Complete this section only if the Dealer listed in Section 1 is a Corporation, Partnership, or other business entity. If the Dealer listed in
Section 1 is an individual or sole proprietorship you may skip this section. Please copy this page as needed to provide information on all
persons associated with the Dealer.
Please complete this section for each officer or partner associated by partnership, corporation, or other business relationship to the Dealer listed in
Section 1.

Position held:
President/CEO
Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name or Name of Business

Mailing Address

Apt/Suite #

Physical Address

Director/Manager

Agent

First Name

Other
Middle Name

Suffix Name

City

State

County

Zip Code

Country

Apt/Suite # City

State

County

Zip Code

Country

Check box if same as Mailing Address

SSN #

Date of Birth

Area Code

Phone Number

Position held:
President/CEO
Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name or Name of Business

Director/Manager

Agent

First Name

Other
Middle Name

Suffix Name

Mailing Address

Apt/Suite #

City

State

County

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County

Zip Code

Country

Check box if same as Mailing Address

SSN #

Date of Birth

Area Code

Phone Number

Page2

5. RECEIVING FACILITIES
INSTRUCTIONS: List the names and street addresses for all facilities where product is recieved. Please copy this page as needed to provide information
on all facilities where fish are received.

AREA CODE

BUSINESS NAME

PHYSICAL ADDRESS

CITY

PHYSICAL ADDRESS

CITY

CITY

PHYSICAL ADDRESS

CITY

PHYSICAL ADDRESS

CITY

PHYSICAL ADDRESS

CITY

PHYSICAL ADDRESS

CITY

COUNTRY

COUNTY

ZIP CODE

COUNTRY

COUNTY

ZIP CODE

COUNTRY

COUNTY

ZIP CODE

COUNTRY

COUNTY

ZIP CODE

COUNTRY

ZIP CODE

COUNTRY

TELEPHONE NUMBER

STATE

Page 3

ZIP CODE

TELEPHONE NUMBER

STATE

AREA CODE

BUSINESS NAME

COUNTY

TELEPHONE NUMBER

STATE

AREA CODE

BUSINESS NAME

COUNTRY

TELEPHONE NUMBER

STATE

AREA CODE

BUSINESS NAME

ZIP CODE

TELEPHONE NUMBER

STATE

AREA CODE

BUSINESS NAME

COUNTY

TELEPHONE NUMBER

STATE

AREA CODE

BUSINESS NAME

PHYSICAL ADDRESS

STATE

AREA CODE

BUSINESS NAME

TELEPHONE NUMBER

COUNTY

6. State Wholesaler Licenses
Complete the following and provide a copy of each state wholesaler's license held by the dealer.
State Wholesaler
License Number :

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License :

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

Other Federal Permits or licenses held (issued from
Federal a permit office outside of the Southeast Region).

7. SIGNATURE
The undersigned certifies under penalty of perjury that the foregoing infomation is true and correct (28 U.S.C. section 1746; 18 U.S.C. section 1621;
18 U.S.C. section 1001).
Please note: The applicant who signs below must be the dealer identified in Section 1 unless the dealer is a partnership, corporation, or other
business entity, in which the applicant must be an individual named as an officer or shareholder of the dealer as listed in Section 4.

Applicant Signature

Date

Printed Name

Position in Company (if applicable)

Payment Reminder:
All applications must include payment of a non-refundable application fee in the form of a check or money order made
payable to the US Treasury. The fee required is $100.00 for the first fishery and $25.00 for each additional fishery
requested with this application.

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing
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 suggestions for reducing this burden to Jason Rueter, National Marine Fisheries Service,
F/SER22, 263 13th Avenue South, St. Petersburg, FL 33701.
The National Marine Fisheries Service requires this information for the conservation and management of marine fishery resources. The data reported
will be used to develop, implement, and monitor fishery management activities for a variety of other uses. Responses to this collection are required to
obtain or retain a fisheries permit under the Magnuson - Stevens Act. Name and address information will be released via a NOAA website. All other
data submitted will be handled as confidential material in accordance with NOAA Administrative Order 216-100, Protection of Confidential Fishery
Statistics. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for
failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information
displays a currently valid OMB Control Number.

Page 4

Instructions for the Federal Application for an Annual Dealer
Permit
ACTIVITIES FOR WHICH PERMITS ARE REQUIRED
DOLPHIN/WAHOO

Under 50 CFR 622.4, a dealer who receives Atlantic dolphin/wahoo harvested in the EEZ off the Atlantic
states (Maine through the East Coast of Florida) must obtain an annual dealer permit.

GOLDEN CRAB
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives South Atlantic golden crab harvested in the EEZ off the
Southern Atlantic states must obtain an annual dealer permit.

REEF FISH
(Gulf of Mexico)

Under 50 CFR 622.4, a dealer who receives reef fish harvested from the EEZ of the Gulf of Mexico
must obtain an annual dealer permit.

ROCK SHRIMP
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives rock shrimp harvested in the EEZ off the Southern Atlantic
states must obtain an annual dealer permit.

SNAPPER-GROUPER
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives South Atlantic snapper-grouper, excluding wreckfish,
harvested in the EEZ off the Southern Atlantic states must obtain an annual dealer permit.

SHARK

Under 50 CFR 635.4, a dealer who receives sharks from the Western North Atlantic Ocean including the
Gulf of Mexico and the Caribbean Sea must obtain an annual dealer permit.

SWORDFISH

Under 50 CFR 635.4, a dealer who receives from a U.S. vessel a swordfish harvested from the Atlantic
Ocean or Gulf of Mexico must obtain an annual domestic dealer permit.

WRECKFISH
(South Atlantic)

Under 50 CFR 622.4(a)(4), a dealer who receives a wreckfish harvested from the South Atlantic must
obtain an annual dealer permit.

INSTRUCTIONS
Complete the following sections, as applicable:
SECTION 1 & 2 Print or type the name of business and address as shown on your business license. If the applicant is a Business,
print or type the Federal Tax ID number assigned to your business by the Internal Revenue Service (taxpayer ID
information) if one has been assigned. If applicant is an individual, enter the Social Security Number (taxpayer ID
information). If the business is corporate owned, the current Articles of Incorporation and a copy of your most recent
Annual Business Report are required to support your application.
As a reminder, permits will not be issued if the corporation is in an INACTIVE status. If your business is not
incorporated, then submit a copy of your local business license.
SECTION 3

Select the fisheries for which you are applying.

SECTION 4

If the application is for a dealer that a corporation, partnership, or other business entity then information on the
dealer’s officers/ shareholders is required. If additional space is needed, please photocopy the blank page as many
times as is necessary to provide information on all officers/shareholders associated with the dealer.

SECTION 5

If fish are received at a location different from the dealer’s address listed in section 2, complete this section for each
physical location where fish are received. Note: A post Office Box is not acceptable as a physical location where fish
are received.

SECTION 6

Provide the state wholesale license for each state in which the dealer has a facility. Also, please provide the permit
number of any Federal Permits issued, for example, a dealer permit issued by the NMFS Northeast Regional Office
(NERO).

SECTION 7

The application must be signed must be signed and data. If the dealer is a corporation, partnership, or other
business entity then the applicant must be an officer or shareholder of the dealer, as indicated on the Articles of
Incorporations (and any amendments) and/or your most recent Annual Business Report.

Additional Instructions:
1. Mail the completed application, copy of state wholesaler’s license (if required) for each state in which you operate, a copy of the
Articles of Incorporation (and any amendments), a copy of the most current Annual Business Report as filed with the state in which the
business is incorporated, and a check or money order made payable to the U.S. TREASURY to: National Marine Fisheries Service
th
(F/SER1), 263 13 Avenue South., St. Petersburg, FL 33701. Questions may be telephoned to 727/824-5326 between 8 am 4:30pm ET. If you would like your permit and associated documents returned to you via overnight mail, enclose a completed
FEDERAL EXPRESS air bill, complete with your delivery address, telephone, and your FEDEX account number or credit card number.
States required to submit wholesale license: Alabama, California, Florida, Georgia, Hawaii, Louisiana, Massachusetts, Maryland,
Maine, Pennsylvania, Rhode Island, South Carolina, Texas, U.S. Virgin Islands and Washington.

2. The application fee is $100 for the first fishery and $25 for each additional fishery and is non-refundable. A check or money order
payable to the U.S. TREASURY must accompany each application. The fee for a replacement permit is $18. Complete all lines or
sections that apply for the type(s) of fishery(ies) requested. Select only those your business will need. Certain fisheries require
mandatory reporting requirements.
In accordance with Federal regulations, any change in your permit information must be reported to the NMFS Regional
Administrator within 30 days of the change.

KNOWINGLY SUPPLYING FALSE INFORMATION FOR THE PURPOSE OF OBTAINING A DEALER PERMIT IS A VIOLATION OF
FEDERAL LAW PUNISHABLE BY A FINE AND/OR IMPRISONMENT.

Rev. 6/2/06 w/o doc clause