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pdfOMB Control No. 0648 -0620; Expiration Date: 11/30/2013
MOTHERSHIP COOPERATIVE
PERMIT
PACIFIC COAST
GROUNDFISH
UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353
Fax (206) 526-4461
www.nwr.noaa.gov
SECTION A - COOPERATIVE CONTACT INFORMATION
TIN
1. Name of Cooperative:
2. Co-op Business Mailing Address (P.O. Box or street address)
3. City
4. State
5. Zip
6. Business Telephone Number:
7. Business Fax Number:
8. E-mail Address (if available):
9. Name of Cooperative Manager:
10. DOB:
Mothership Cooperative Permit Application
Page 1 of 7
OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
SECTION B –MS/CV PERMITS OBLIGATED TO COOPERATIVE –
List all MS/CV Permits Numbers, MS/CV Endorsement and Catch History Registration Number and associated whiting catch
history assignment amounts (Add additional pages if necessary)
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Permit Number: GF0
MS/CV Endorsement and CHA
Registration Number:
Whiting Catch History Assignment %:
Mothership Cooperative Permit Application
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OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
Total Co-op Whiting Allocation (sum of permit whiting catch history
assignments expressed as %):
Mothership Cooperative Permit Application
Page 3 of 7
OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
SECTION C - VESSEL INFORMATION List all co-op member catcher vessels. List complete information for each co-op catcher vessel member
(attach additional pages if necessary).
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USGC No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USGC No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USGC No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4.. USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. . USCG No.:
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USCG No.:
Mothership Cooperative Permit Application
Page 4 of 7
OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
1. Vessel Name:
2. USGC No.:
3. Designated MS Vessel Name
4. USGC No.:
Section D – Certification and Notary
Under penalties of perjury, I hereby declare that I, the undersigned, is authorized to sign this form on behalf of the applicant and completed this form, and
the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative
Date
Printed Name of Authorized Representative (NOTE: attach authorization, if needed)
Notary Public Signature
“ ATTEST
Affix Notary Stamp or Seal Here
Date Commission Expires
WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil penalty of up to
$140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.
PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of this collection.
The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a unique identification for
assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The information collected is part of a Privacy Act
System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated Fisheries. A notice was published in the Federal Register on April
17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).
PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 2.0 hours per response, including the time for reviewing the 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 aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest Region, Attn:
Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Some of the information collection described above is
confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number,
fax, email, TIN, and DOB are not released to the public. The names of individuals who have an ownership interest in an entity that owns a permit, vessel or processing plant and
the actual percentage of ownership are considered business confidential and released to the public.
Mothership Cooperative Permit Application
Page 5 of 7
OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
MOTHERSHIP COOPERATIVE
PERMIT
PACIFIC COAST
GROUNDFISH
UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353
Fax (206) 526-4461
www.nwr.noaa.gov
Instructions
Deadline Date March 31, 2012
This form must be completed and submitted to the National Marine Fisheries Service (NMFS) to the address given above in
order to apply for and obtain a mothership cooperative (coop) permit. This application must be postmarked no later than
March 31, 2011. This permit authorizes the cooperative to operate in the whiting mothership fishery.
Section A – Cooperative Contact Information
The applicant must provide the name of cooperative business entity as given with the state registered in, tax identification
number, business mailing address, phone number, fax number and email address. The applicant must provide the name of
the manager of the cooperative and their date of birth.
Section B – MS/CV Permits and Catch History Assignment Obligated to Coop
The applicant must provide the permit number for all MS/CV endorsed Pacific Coast limited entry permits being assigned to
the coop, the registration number for each of the MS/CV endorsement and catch history assignment being assigned to the
coop and the associated whiting catch history assignment amounts (expressed as percentage). If Section B does not
provide sufficient space to list all permits, please make a copy of this section, add the additional permits and catch history
assignment amounts and append to the application. Please note: A cooperative must have a minimum of 20% of all permit
holders to form a co-op. The applicant must indicate the total whiting catch history allocation that will accrue to the coop
based on the sum of the individual MS/CV permits obligated to the coop.
Section C – Catcher Vessels and Mothership Obligation
The applicant must list the name and USCG vessel documentation number for each catcher vessel fishing for the coop and
provide the name and USCG vessel documentation number of the mothership each catcher vessel is obligated to.
Section D - Certification of Applicant and Notary:
The applicant or authorized representative must sign and date the form in the presence of a notary to certify that the
individual(s) signing the form have satisfactorily identified themselves. By signing and dating the form, the applicant or
authorized representative certifies that all information set forth in the form is true, correct, and complete to the best of the
applicant's knowledge and belief. The form will not be considered without the authorized representative’s signature. The
notary must sign and date this section, and affix notary stamp or seal.
If the applicant is business entity, the authorized representative must include a copy of the corporate resolution or
other document authorizing the individual to sign and certify on behalf of the business entity. .
Mothership Cooperative Permit Application
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OMB Control No. 0648 -0620; Expiration Date: 11/30/2013
Supplemental Documentation Required:
The applicant must provide a copy of the cooperative agreement consistent with the regulations given at
660.XXX.
The applicant must provide any inter-coop agreement entered into at the time of application.
Mothership Cooperative Permit Application
Page 7 of 7
| File Type | application/pdf |
| File Title | C:\PRA\OMB83I pre-ps.WP6.wpd |
| Author | rroberts |
| File Modified | 2011-08-04 |
| File Created | 2011-08-04 |