Form 3-1383-G General Special Use Application and Permit

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

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

National Wildlife Refuge System
General Special Use
Application and Permit

Name of Refuge
Address

Attn: (Refuge Official)

Application:
Phone #

(To be filled out by applicant. Note: Not all information is required for each use.
See instructions at the end of the notice.)

1)

New

Renewal

Modification

E-mail

Other

Applicant Information:
2) Full Name:

6) Phone #:

3) Organization:

7) Fax #:

4) Address:

8) E-mail:

5) City/State/Zip:
9) Assistants/Subcontractors/Subpermittees: (List full names, addresses and phone #'s and specifically describe services provided if
subcontractors are used.)

Activity Information:
10) Activity Type:

Event

Wood Cutting

Group Visit

Cabin/Subsistence Cabin

Educational Activity

Other

11) Describe Activity: (Specifically identify timing, frequency, and how the event is expected to proceed.)

12) Activity/site occupancy timeline: (Specifically identify beginning and ending dates, site occupation timeline, hours, clean-up and other major
events.)

FWS Form 3-1383-G
03/11

(Depending on the activity for which you are requesting a permit, we may ask you for the following activity information.
Please contact the specific refuge where the activity is being conducted to determine what activity information is required.)

13) Expected number of participants:
Children

Adults

Yes

14) Grade level of educational group:

Total

15) Will staff time/assistance be required?
No

N/A

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

N/A

Grade

16a) Plan of Operation required?

Yes

No

16b) Plan of Operation attached?

Yes

No

N/A

17) Location: (Specifically identify location; GPS location preferred.)

18a) Is map of location(s) required?
Yes

No

18b) Is map of location(s) attached?

N/A

Yes

No

Insurance Coverage/Certifications/Permits:
19a) Is insurance required?
Yes

No

19b) Insurance: (Provided carrier, type and policy number)

N/A

20) Other licenses/certifications/permits required: (Specifically identify licenses, certifications, and permits.)

Logistics and Transportation:
21) Does activity require personnel to stay overnight onsite?
22) Personnel involved:

Yes

No

23) Specifically describe all equipment/gear and
materials used:

24) Transportation description(s) and license number(s) to access refuge(s): [Provide description of and specific
auto license/boat/plane registration number(s).]

25) Specifically describe onsite work and/or living
accommodations:

26) Specifically describe onsite hazardous material storage or
other onsite material storage space:

27) Signature of Applicant _________________________________ Date of Application ____________
Print Form

Sign, date, and print this form and return it to the refuge for processing. Do not fill out information below this
page.
FWS Form 3-1383-G
03/11

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

For Official Use Only: (This section to be filled out by refuge personnel only.)

Special Use Permit:

Permit #:
2) Permit
Approved

1) Date:

Permit
Denied

3) Station # :

4) Additional special conditions required: (Special conditions may include activity reports, before and after photographs, and other conditions.)
Yes

No

N/A

Additional sheets attached:

5) Other licenses/permits required:
Yes

No

No

Verification of other licenses/permits, type:

Verification of insurance/certification, type:

N/A

7) Record of Payments:

Exempt

Partial

Amount of payment
8) Bond posted:

No

N/A

6) Insurance/certifications required:
Yes

Yes

Full
Record of partial payment

Yes

No

This permit is issued by the U.S. Fish and Wildlife Service and accepted by the
applicant signed below, subject to the terms, covenants, obligations, and
reservations, expressed or implied herein, and to the notice, conditions, and
requirements included or attached. A copy of this permit should be kept on hand so
that it may be shown at any time to any refuge staff.
Permit approved and issued by (Signature and title):
________________________________

Date:___________

Permit accepted by (Signature of applicant):
________________________________

Date:___________

FWS Form 3-1383-G
03/11

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

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 are 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 any 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.
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 response 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 Department (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 for the General Use Special Use Permit
Application form is estimated to average 30 minutes 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, U.S. Fish and Wildlife Service, 4401 N.
Fairfax Drive, MS 2042-PDM, Arlington, Virginia, 22203.
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 Government 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.
FWS Form 3-1383-G
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OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

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 activity.
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.
Instructions for Completing Application
You may complete the application portion verbally, in person or electronically and submit to the refuge for review. Note: Please read instructions carefully as
not all information is required for each activity. Contact the specific refuge headquarters office where the activity is going to be conducted if you have
questions regarding the applicability of a particular item.
1. Identify if permit application is for new, renewal or modification of an existing permit. Permit renewals may not need all information requested. Contact the
specific refuge headquarters office where the activity is going to be conducted if you have questions regarding the applicability of a particular item.
2-8. Provide full name, organization (if applicable), address, phone, fax, and e-mail.
9. Provide names and addresses of assistants, subcontractors or subpermittees. Names and address are only required if the assistants, subcontractors or
subpermittees will be operating on the refuge without the permittee being present. Volunteers, assistants, subcontractors or subpermittees that are
accompanied by the permittee need not be identified.
10. Activity type: check one of the following categories:
a. Event
b. Wood cutting;
c. Group visit;
d. Cabin/Subsistence cabin;
e. Educational activity; or
f. Other - any other activity(s) not mentioned above. Please describe "other" activity.
11. Describe Activity: provide detailed information on the activity, including times, frequency and how the activity is expected to proceed, etc. Permit
renewals may not need activity description, if the activity is unchanged from previous permit. Most repetitive activities, such as group visits, do not require an
activity description for each visit. Contact the specific refuge headquarters office where the activity is going to be conducted to determine if an activity
description is required.
12. Activity/site occupancy timeline: identify beginning and ending dates, site occupation timeline, hours, clean-up and other major events. Permit renewals
may not need an activity/site occupancy timeline, if the activity is unchanged from previous permit. Most repetitive activities, such as group visits, do not
require an activity/site occupancy timeline for each visit. Contact the specific refuge headquarters office where the activity is going to be conducted to
determine if an activity/site occupancy timeline is required.
13-14 Expected number of participants: Provide an estimate of the number of adults, and children and grade level of group, if applicable.
15. Identify if onsite refuge staff will be required for group activities and anticipated time frame, if applicable.
16a-16b. Identify and attach Plan of Operation, if required. Most repetitive activities, such as group visits, do not require Plans of Operations for each visit. In
addition, permit renewals may not require Plans of Operations if the activity is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if a Plan of Operations is required.
17. Location: identify specific location (GPS coordinates preferred), if not a named facility. Most repetitive activities, such as group visits, do not require a
location. In addition, permit renewals may not require a location if the activity is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if a location is required.
18a-18b. Attach a map of location, if required and not conducted at a named facility. Most repetitive activities, such as group visits, do not require a map. In
addition, permit renewals may not require a map if the activity is essentially unchanged from the previous permit. Contact the specific refuge headquarters
office where the activity is going to be conducted to determine if a map is required.
19a-19b. Provide name, type and carrier of insurance, if required. Contact the specific refuge headquarters office where the activity is going to be conducted
to determine if insurance and type of insurance are required.
20. Specifically identify types and numbers of other licenses, certifications or permits, if required. Contact the specific refuge headquarters office where the
activity is going to be conducted to determine the types of licenses, certifications or permits required, and to coordinate the simultaneous application of
several types of licenses, certifications or permits. This Special Use Permit (SUP) may be processed while other certifications are being obtained.
21-22. Provide name(s) of any personnel required to stay overnight, if applicable.
23. Identify all equipment and materials, which will be used, if required. Most repetitive events, such as group visits, do not require a list of equipment. In
addition, permit renewals may not require a list of equipment if the event is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if a list of equipment is required.
FWS Form 3-1383-G
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OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

24. Describe and provide vehicle descriptions and license plate or identification numbers of all vehicles, including boats and airplanes, if required. Motor vehicle
descriptions are only required for permittee vehicle, and/or if the vehicle will be operated on the refuge without the permittee being present. Motor vehicles that
are accompanied by the permittee as part of a group (convoy) activity need not be identified if cleared in advance by refuge supervisor. Specifically describe
ship-to-shore, intersite (between islands, camps, or other sites) and onsite transportation mechanisms, and license plate or identification numbers, if required.
25. Specifically describe onsite work and/or living accommodations, if applicable.
26. Specifically describe onsite hazardous material storage, or other onsite material storage space (including on and offsite fuel caches).
27. Sign, date, and print the application. Click on the Print button to print the application (if using the fillable version). The refuge official will review and, if
approved, fill out the remaining information, sign, and return a copy to you for signature and acceptance.

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.

FWS Form 3-1383-G
03/11