American Samoa Pelagic Longline Limited Access Program -

OMB NUMBER: 0648-0490
Expires: xx/xx/xx

FEDERAL FISHERIES APPLICATION FORM
PACIFIC ISLANDS REGION
NATIONAL MARINE FISHERIES SERVICE
1601 Kapiolani Blvd., Suite 1110
Honolulu, HI 96814-4700
Ph: (808) 944-2200; Fax: (808) 973-2940

PLEASE PRINT RESPONSES
Version: xx/xx/xx

American Samoa Pelagic Longline Limited Access Program
Limited Entry Permit Application
Application Type (check only one type):

Mail or deliver completed application form to Pacific Islands Region, ATTN: Permits.

(Non-Refundable Application Processing Fee: $XX.00, payable by check or money order to: Department of Commerce, NOAA. Fee
charged for all permit transactions unless otherwise noted below)
PERMIT CLASS SIZE: G A = 40’ or less G B = 40.1’ – 50’

Permit Renewal OR

G C = 50.1’ – 70’

Additional Permit Issuance (Please indicate permit class size):

G D = 70’ or larger

Registration of vessel to initial permit or re-registration (applies to vessels which have been sold or sunk): [No application
processing fee charged for initial registration of vessel to initial permit]

Permit transfer (for permits registered to vessels of size Class A, B, C, and D, and Class B-1, C-1, and D-1 after three years)
To: G Family member
G Community organization
G Person with documented participation in the American Samoa
longline fishery (participation in vessel size Class A for Class A only)
NAME: ____________________________________________________
(Print first and last names, or name of community organization)

VESSEL NAME: ___________________________________

Family Relationship: _______________________
(if Family member is checked)

VESSEL NUMBER (USCG or AS): _____________________

VESSEL OWNER: ________________________________________________ VESSEL RADIO CALL SIGN: _____________________
PERMIT HOLDER: ___________________________________________ TAXPAYER IDENTIFICATION NUMBER:_________________
(First, Middle and Last Name, or Business Name)
(if a business)
PERMIT HOLDER DATE OF BIRTH (individual) or INCORPORATION (business):
Use the Supplementary Information Sheet to list names and addresses of owners, partners or officers.
Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize collection of this information. This information is used to verify the identity of the applicant(s) and
to accurately retrieve confidential records related to federal permits. The primary purpose for requesting the Taxpayer Identification Number is for the collection and reporting on
any delinquent amounts arising out of such person’s relationship to the government pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134). Personal
information is confidential and protected under the Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.

BUSINESS MAIL ADDRESS: _________________________________________, ______________________, _______ __________
(Number, street, apt. no.)

BUSINESS PHONE: (_____)_____________________ (required)

(City/Village)

CELL: (

(State)

(Zip)

)

(Please include the area code for each number)

FAX: (

)

EMAIL:

PERMIT APPLICANT: _____________________________________ _______________________________ DATE: _______________
[if applicant is an agent, see note 4 below]

(Print first, middle and last name)

(Signature)

Additional permit, permit renewal or upgrade, and vessel registration: Permit holder or applicant fills out “Permit Applicant” information above.
Permit transfers: The transferring permit holder completes Permit Transferor information below and signs, and the person receiving the permit completes and signs
the Permit Applicant information above.

PERMIT TRANSFEROR: ____________________________________/________________________________ DATE: ____________
(Current holder)

(Print first and last name)

(Signature)

PERMIT NUMBER BEING TRANSFERRED: __________________________
Please submit the appropriate required documents:
1) Payment for the non-refundable application processing fee, if required,
2) A copy of the vessel’s current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from the state/territorial
agency (undocumented vessel) to register a vessel to the permit,
3) Documentation of participation in the American Samoa longline fishery if applying for an Additional Permit, Permit Transfer, or Permit Upgrade, and
4) Signed letter from permit holder authorizing the permit applicant as their agent, if the agent is submitting the application.
If your application is incomplete, you will be notified by PIRO. You have 30 days from the date of notification to provide required documents, or your
application will be considered abandoned. It is prohibited to file false information on an application for a fishing permit (50 CFR 665.15(b)).

OMB Control No. 0648-0490
Expiration Date: xx/xx/xxxx

American Samoa
Pelagic Longline Limited Access Program
Limited Entry Permit Application
SUPPLEMENTARY INFORMATION SHEET
Company/Corporation officers, owners, or partners:
NAME

MAILING ADDRESS

PERCENT OWNERSHIP

Check boxes are for office use only:

Previous ownership of longline vessel: Vessel Name: ___________________USCG COD _______ or AS Vsl Reg. _______

Vessel used to legally harvest Pacific pelagic management unit species with longline gear in the EEZ around American Samoa.

Fulfilled Minimum Catch Requirements for Renewal

Current Protected Species workshop certification (for renewal)
Documented Ownership or Evidence of Work (Participation) on AS Longline Fishing Vessel:

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PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 45 minutes for American Samoa longline limited access initial permit issuance, renewal, transfer or
upgrade; 2 hours for permit appeal. Send comments regarding this burden estimate and any other aspects of this collection of information, including suggestions for reducing
this burden, to Regional Administrator, NMFS Pacific Islands Region, 1601 Kapiolani Blvd., Suite 1110, Honolulu, Hawaii 96814-4700.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Western Pacific
Region. This will enable NMFS and the Western Pacific Fishery Management Council to (a) determine who would be affected by changes in management; (b) inform
license holders of changes in fishery regulations; and (c) determine whether the objectives of the fishery program are being achieved by monitoring entry and exit patterns
and other regulatory changes on person in the regulated fisheries as well as in related fisheries. Responses to the collection are required to obtain the benefit of a license for
the fishery involved (ref. 50 CFR 665.13). Data provided concerning the vessel and/or business of the respondents are handled as confidential under the Magnuson-Stevens
Fishery Conservation and Management Act (Sec. 402 (b)). Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be
subject 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 Numbers.

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