Federal Permit Application for an Annual Dealer Permit

OMB No. 0648-0205 Form Approval Expires: 08/31/2011

U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS OFFICE, F/SER14

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)
877/376-4877 toll free (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 and Amount
Sanction Case Number if
Sanctioned
SERO Dealer Number
Application ID
Expiration Date

FOR OFFICE USE ONLY

1. DEALER INFORMATION
Dealer entity is (check one):

INDIVIDUAL or SOLE PROPRIETORSHIP

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

Federal Tax ID Number

Date business was filed
(MM/DD/YYYY)

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

Last Name

Tax ID # (SSN)

First Name

Date of Birth (MM/DD/YYYY)

Middle Name

Area Code

Suffix: JR,SR, etc.

Phone Number

2. DEALER CONTACT INFORMATION

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Street Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Area Code

Phone Number

Valid E-Mail Address

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Form Revision 05/27/2011

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 (RSD)

Domestic Swordfish (SD)

South Atlantic Golden Crab (GCD)

South Atlantic Snapper-Grouper
Excluding Wreckfish (SGD)

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, 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

Director/Manager

Agent

First Name

Other

Suffix - Jr,Sr,etc

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Area Code

Date of Birth (MM/DD/YYYY)

SSN

Phone Number

Position held:
President/CEO

Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name

Director/Manager

Agent

First Name

Other

Suffix - Jr,Sr,etc

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

SSN

Area Code

Date of Birth (MM/DD/YYYY)

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Phone Number

5. RECEIVING FACILITIES
INSTRUCTIONS: List the names and street addresses for all facilities where product is received (fish is off loaded from the fishing vessels). Please copy
this page as needed to provide information on all facilities where fish are received.
CHECK HERE IF THE STREET ADDRESS YOU GAVE ON PAGE ONE IS ALSO A FACILITY WHERE YOU RECEIVE FISH FROM THE FISHERMEN. IF IT IS A RECEIVING FACILITY - ONLY
THOSE FACILITIES THAT ARE AT A DIFFERENT LOCATION ON THIS PAGE

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

STAT

Page 3

ZIP CODE

TELEPHONE NUMBER

STAT

AREA CODE

BUSINESS NAME

COUNTY

TELEPHONE NUMBER

STAT

AREA CODE

BUSINESS NAME

COUNTRY

TELEPHONE NUMBER

STAT

AREA CODE

BUSINESS NAME

ZIP CODE

TELEPHONE NUMBER

STAT

AREA CODE

BUSINESS NAME

COUNTY

TELEPHONE NUMBER

STAT

AREA CODE

BUSINESS NAME

PHYSICAL ADDRESS

STAT

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 a
Federal permit office outside of the Southeast Region).

7. SIGNATURE
The undersigned certifies under penalty of perjury that the foregoing information 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 business 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 U.S. Treasury. The fee required is $50.00 for the first fishery and $12.50 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 PRA Officer, National Marine Fisheries Service,
F/SER2, 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.

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