Federal Permit Application for Southeast Region Vessel O

Text463:

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

REQUIRED FOR SOUTH ATLANTIC ROCK SHRIMP
AND/OR ATLANTIC DOLPHIN WAHOO
U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS OFFICE, F/SER14

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

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

FOR OFFICE USE ONLY

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

FEE: $50.00
REPLACEMENT CARD $18.00

1-877-376-4877 Toll Free
http://sero.nmfs.noaa.gov

Application ID

FOR OFFICE USE ONLY
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 DELAY 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

AREA CODE

COUNTRY

TELEPHONE NUMBER

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
MALE
FEMALE

SOCIAL SECURITY NUMBER

BIRTH PLACE (CITY, STATE, COUNTRY)

HAIR COLOR

EYE COLOR
GREEN

BROWN

BLONDE

BLUE

HAZEL

BLACK

RED

GREY

Other

GREY

Other

BROWN

________

WHITE

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

WEIGHT (LBS)

HEIGHT (FEET - INCHES)

________

SIGNATURE
Applicant Signature

Print Name

Date

Last Form Revision 05/17/2011