Mothership Limited Entry Permit Renewal

OMB Control No. 0648-0203, Expiration Date 04/30/2010

MS PERMIT RENEWAL
FORM
PACIFIC COAST GROUNDFISH
Limited Entry Permit

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
www.nwr.noaa.gov

Fax (206) 526-4461

Please make any changes as appropriate to the addresses, phone and fax number and email address listed below.
Please sign, date and return the form with payment. Any changes in vessel registered to the permit, or a change
of a permit or vessel owner will require submission of a permit transfer form.
Permit Number:
Permit Owner:
Permit Owner's name(s):
Business Address:
Business Phone:
Fax Number:
Email address:
Date of Birth (For each individual given):
Vessel Owner:
Vessel Owner name (s):
Business address:
Business phone:
Fax number:
Email address
Date of Birth (For each individual given):
Vessel name
Vessel Official number
Endorsements (Gear, Size):
Please sign below to certify that the above information is true, correct and complete (edit if necessary) to the
best of your knowledge and return this form with a check or money order for $XXXX made payable to U.S.
Department of Commerce, NOAA. Mail to: NOAA/NMFS/Northwest Region, Sustainable Fisheries
Division, 7600 Sand Point Way NE, Bldg. #1 Seattle, WA 98115-0070.
____________________________________________________________________________
Signature of owner(s)
Title (If corporate officer)
Date
Print Name of Signatory: __________________________
Warning Statement: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15
CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and as a federal crime under 18 USC 1001
PRIVACY ACT STATEMENT: Phone number, fax and email information are not released to the public. The permit sale/lease
information and the amount of sablefish landed to date given on a transfer form are considered confidential. Similarly, the names
associated with a entity that owns a sablefish permit or has vessel registered to sablefish endorsed permit are confidential, as are date of
birth for an individual and any medical records provided to obtain an exemption from the owner on board required. Some of the
information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act. It is also confidential under
NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics.

MS Permit Renewal Application
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The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations 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 0.33 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

MS Permit Renewal Application
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