Form 3-1383 Special Use Application and Permit

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

2. Application Date

Special Use Application and Permit

3. Period of Use Applying for:

National Wildlife Refuge From:

1.

To:

4. Applicant Information:
Name

Phone:

Organization:

Fax:

Address:

email

City/State/ZIP
5. Purpose of the Permit Application:
Agriculture

Commercial Visitor Services

Commercial Activities

Commercial Filming

Research/Monitoring

Special Event

Other (describe)

6. Describe the above activity as specifically as you can.
Include: Where the activity will take place (units, roads, trails); When (seasons, days, hours); How (methods, techniques, transportation); Frequency (one
time only, daily, occassionally); Number of people/vehicles/boats; Special Needs/access
Researchers may be required to supply a research proposal.

7. Print Form

8. Applicant Signature:

Date:

Print this form and return it to the refuge for processing. Do not fill out any information below this line.
For Official Use Only:
Special Conditions:

Record of Payments:

Application approved:
Station Number:
Permit Number:
Payment exempt
Amount of fee:
Full Payment:

yes

no

Partial Payment
Record of Partial Payments:

This permit is issued by the U.S. Fish and Wildlife Service and accepted by the above signed, subject to the terms, convenants, obligations, and reservations, expressed or implied herein, and to the
notice, conditions, and requirements appearing on the reverse side.

Permit Approved and Issued By: (name and title)

FWS Form 3-1383 (Rev. 01/08)

Date:

OMB Control No. 1018-0102, Expires XX/XX/2011

Notice
In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork Reduction Act (44 U.S. C. 3501), please note the following information:
1. The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System is authorized by the National Wildlife Refuge
System Administration Act (16 U.S. C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4).
2. The information that you provide is voluntary; however submission of requested information is required to evaluate the qualifications,
determine eligibility, and document permit applicants under the above Acts. It is our policy not to use your name for ony other purpose. The
information is maintained in accordance with the Privacy Act. All information you provide will be considered in reviewing this application. False,
fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the Special Use Permit and may
be punishable by fine or imprisonment (18 U.S.C. 1001). Failure to provide all required information is sufficient cause for the U.S. Fish and
Wildlife Service to deny a permit. Response is not required unless a currently valid Office of Management and Budget (OMB) control number is
displayed.
3. No members of Congress or Resident Commissioner shall participate in any part of this contract or to any benefit that may arise from it, but
this provision shall not pertain to this contract if made with a corporation for its general benefit.
4. The Permittee agrees to be bound by the equal opportunity "nondiscrimination in employment" clause of Executive Order 11246.
5. Routine use disclosures may also be made: (a) to the U.S. Department of Justice when related to litigation or anticipated litigation; (b) of
information indicating a violation or potential violation of a statute, rule, order, or license to appropriate Federal, State, local or foreign agencies
responsible for investigating or prosecuting the violation or for enforcing or implementing the statute, rule, regulations, order, or license; (c) from
the record of the individual in reponse to an inquiry from a Congressional office made at the request of the individual (42 FR 19083; April 11,
1977); and (d) 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 Deparment (48 FR 54716; December 6, 1983).
6. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number. This information collection has been approved by OMB and assigned control number 1018-0102. The public
reporting burden for this information collection varies based on the specific refuge use being requested. The relevant public reporting burden
estimate for the Special Use Permit Application form is estimated to average one hour per response, including time for reviewing instructions,
gathering and maintaining data, and completing and reviewing the form. Comments on this form should be mailed to the Information Collection
Clearance Officer, Mail Stop 222, Arlington Square, U.S. Fish and Wildlife Service, Arlington, Virginia, 22203. Thank you.
General Conditions and Requirements.
1. Responsibility of Permittee: The permittee, by operating on the premises, shall be considered to have accepted these premises with all
facilities, fixtures, or improvements in their existing condition as of the date of this permit. At the end of the period specified or upon earlier
termination, the permittee shall give up the premises in as good order and condition as when received except for reasonable wear, tear, or
damage occurring without fault or negligence. The permittee will fully repay the Service for any and all damage directly or indirectly resulting
from negligence or failure on his/her part, and/or the part of anyone of his/her associates, to use reasonable care.
2. Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all
municipal, county, and State laws applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing
national wildlife refuges and the area described in this permit. The permittee shall comply with all instructions applicable to this permit issued by
the refuge official in charge. The permittee shall take all reasonable precautions to prevent the escape of fires and to suppress fires and shall
render all reasonable assistance in the suppression of refuge fires.
3. Use Limitations: The permittee's use of the described premises is limited to the purposes herein specified and does not, unless provided for
in this permit, allow him/her to restrict other authorized entry onto his/her area; and permits the Service to carry on whatever activities are
necessary for: (1) protection and maintenance of the premises and adjacent lands administered by the Service; and (2) the management of
wildlife and fish using the premises and other Service lands.
4. Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or
interest not mentioned in this permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the
Regional Director of the Service and the permit shall not be used for speculative purposes.
5. Compliance: The Service's failure to require strict compliance with any of this permit's terms, conditions, and requirements shall not
constitute a waiver or be considered as a giving up of the Service's right to thereafter enforce any of the permit's terms or conditions.
6. Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, all money paid under
this permit shall be retained by the Goverment to be used to satisfy as much of the permittee's obligation as possible.
7. Payments: All payment shall be made on or before the due date to the local representative of the Service by a postal money order or check
made payable to the U.S. Fish and Wildlife Service.

8. Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the Service representative,
reserving, however, the rights specified in paragraph 11. If he/she fails to do so, he/she will pay the government, as liquidated damages, an
amount double the rate specified in this permit for the entire time possession is withheld. Upon yielding possession, the permittee will still be
allowed to reenter as needed to remove his/her property as stated in paragraph 11. The acceptance of any fee for the liquidated damages or
any other act of administration relating to the continued tenancy is not to be considered as an affirmation of the permittee's action nor shall it
operate as a waiver of the Government's right to terminate or cancel the permit for the breach of any specified condition or requirement.
9. Revocation Policy: This permit may be revoked by the Regional Director of the Service without notice for noncompliance with the terms
hereof or for violation of general and/or specific laws or regulations governing national wildlife refuges or for nonuse. It is at all times subject to
discretionary revocation by the Director of the Service. Upon such revocation the Service, by and through any authorized representative, may
take possession of the said premises for its own and sole use, and/or may enter and possess the premises as the agent of the permittee and for
his/her account.
10. Damages: The United States shall not be responsible for any loss or damage to property including, but not limited to, growing crops,
animals, and machinery or injury to the permittee or his/her relatives, or to the officers, agents, employees, or any other who are on the
premises from instructions or by the sufferance of wildlife or employees or representatives of the Government carrying out their official
responsibilities. The permittee agrees to save the United States or any of its agencies harmless from any and all claims for damages or losses
that may arise to be incident to the flooding of the premises resulting from any associated Government river and harbor, flood control,
reclamation, or Tennessee Valley Authority activitiy.
11. Removal of Permittee's Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the
Government have been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the refuge official in
charge, but not to exceed 60 days, remove all structures, machinery, and/or equipment, etc. from the premises for which he/she is responsible.
Within this period the permittee must also remove any other of his/her property including his/her acknowledged share of products or crops
grown, cut, harvested, stored, or stacked on the premises. Upon failure to remove any of the above items within the aforesaid period, they shall
become the property of the United States.
12. Collected Specimens: You may use specimens collected under this permit, any components of any specimens (including natural
organisms, enzymes, genetic materials or seeds), and research results derived from collected specimens for scientific or educational purposes
only, and not for commerical purposes unless you have entered into a Cooperative Research and Development Agreement (CRADA) with us.
We prohibit the sale of collected research specimens or other transfers to third parties. Breach of any of the terms of this permit will be grounds
for revocation of this permit and denial of future permits. Furthermore, if you sell or otherwise transfer collected specimens of any components
without a CRADA, you will pay us a royalty rate of 20 percent of the gross revenue from such sales. In addition to such royalty, we may seek
other damages and injunctive relief against you.
Instructions for Completing Application:
You may complete the application portion electronically and submit to the refuge for review.
1. Enter the name of the refuge at which you are applying for a permit.
2. Under Application Date, fill in the date of application.
3. Under Period of Use, fill in the date(s) for which the activity is requested (inclusive)
4. Under Applicant Information, fill in your name, organization (if applicable), address, phone, fax, and email.
5. Under Purpose, check one of the following categories:
a. Agriculture - haying, grazing, crop planting, logging, beekeeping, and other agricultural products.
b. Commerical activities - commercial fishing, trapping, and other commercial activities.
c. Research/Monitoring - any investigations or monitoring projects proposed for the refuge.
d. Commercial filming - audio, video, and photographic products with a monetary value.
e. Commerical visitor services - outfitters/guides; for hunting, fishing, canoing, kayaking; and other visitor services.
f. Special Events - weddings, fishing tournaments, one-time events, and other special events.
g. Other - specificy any other activity(ies) not mentioned above.
6. Under Describe the Above Activity, provide detailed information on the activity, including locations, times, methods, routes of travel, number
of people, types and number of vehicles, etc. If you are proposing a research project, you may be asked to submit a research proposal.
Contact the refuge for details.
7. Click on the Print button to print the application (if using the fillable version).
8. Under Applicant Signature and Date, sign and date the application, then submit to the refuge per their instructions (fax, mail, in-person)
9. The refuge official will review and, if approved, fill out the remaining information, sign, and return a copy to you.

The form is not valid as a permit unless it includes refuge approval, a station number,
a refuge-assigned permit number, and is signed by a refuge official.