Federal permit application for Southeast Region operator

Text463:

FEDERAL PERMIT APPLICATION
FOR SOUTHEAST REGION ISSUED
OPERATOR CARD
PAPERCLIP
PASSPORT STYLE
PHOTOS HERE. NO
STAPLES, GLUE OR
TAPE.

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

Check or Money
Order Number:
Reviewer Initials and
Date
Expiration Date:

REQUIRED FOR SOUTH ATLANTIC ROCK SHRIMP
AND/OR ATLANTIC DOLPHIN WAHOO
U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS BRANCH, F/SER1

FOR OFFICE USE ONLY

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

FEE: $50.00

http://sero.nmfs.noaa.gov

REPLACEMENT CARD $18.00

GENERAL INSTRUCTIONS: Operator cards are required by the operator of a commercial vessel or charter/headboat fishing for Atlantic Dolphin and/or Wahoo,
or by the operator of a commercial vessel fishing for South Atlantic Rock Shrimp. Applications must be legible, illegible applications will be returned. Fees are
payable by check or money order to the U.S. Treasury. FAILURE TO COMPLY WITH THESE INSTRUCTIONS MAY RESULT IN DELAYS OR DENIAL OF AN
OPERATOR CARD.
APPLICATION INSTRUCTIONS: All blanks in section 1 must be filled in. Use section 2 only if you have a mailing address that is different from the street
address required in section 1. Information is required for all catagories in section 3 including your telephone number. Please list a number where you can be
reached or a message left for you if we have any questions. You must provide two (2) recent (less than 1 year old) passport style photos in 2 inch X 2 inch
size. The photos must have a plain white background and your face must be unobstructed by sunglasses, hats, scarves, etc. Vision correcting glasses are
permitted. Do not staple, glue or tape the photos to the application. You must provide your social security number.

1. VESSEL OPERATOR (CARD OWNER) INFORMATION
LAST NAME

FIRST NAME

MIDDLE NAME

Suffix (Sr., Jr. II, etc)

STREET ADDRESS (NO POST OFFICE BOX ADDRESSES WILL BE ACCEPTED)

CITY

STATE

COUNTY

ZIP CODE

COUNTRY

2. MAILING ADDRESS - ONLY IF DIFFERENT FROM STREET ADDRESS GIVEN IN SECTION 1
MAILING ADDRESS

CITY

STATE

COUNTY

ZIP CODE

COUNTRY

3. IDENTIFYING INFORMATION
DATE OF BIRTH (MM/DD/YYYY)

SEX

EYE COLOR

SOCIAL SECURITY NUMBER

HAIR COLOR

MALE

BROWN

BROWN

FEMALE

BLUE

BLACK

GREY

BLONDE

GREEN

RED

HAZEL

GREY

Other

WHITE

________

BIRTH PLACE (CITY, STATE, COUNTRY)

WEIGHT (LBS)

If you are
clean shaven
or balding,
indicate your
actual hair
color

AREA CODE

HEIGHT (FEET - INCHES)

TELEPHONE NUMBER

Other
________

SIGNATURE
Applicant Signature

Print Name

Date

Last Form Revision 06/24/2005