Aquacultured Live Rock Deposit Harvest Report

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

REPORT FOR THE DEPOSIT OR
HARVEST OF AQUACULTURED LIVE
ROCK

263 13TH Avenue South
St. Petersburg, FL 33701
Toll Free 877/376-4877 8:00 am - 4:30 pm ET

OMB No. 0648-205 Form
Approval expires 08/31/2011
Form revised 04JAN2011

727/824-5326 (8:00 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

FOR OFFICE USE ONLY
Reviewer Initials and
Date Entered

INSTRUCTIONS: Complete section 1 and either section 2 or 3 with all information. Please sign, date, and print your name in
section 4.

1. PERMIT HOLDER INFORMATION
Permit holder as shown on the permit

Site number the material was
deposited to or harvested from

2. DEPOSIT INFORMATION
Name of the source/supplier of the deposited material

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

Geographic origin of the deposited material

Date Deposited (dd/mm/yyyy)

Average Dimensions (inches) ( e.g. 12" x 12")

Total Weight Deposited (Pounds)

3. HARVEST INFORMATION - REQUIRED ONLY IF LANDED OUTSIDE THE STATE OF FLORIDA
Name of the purchaser of the harvested material

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

Date Harvested (dd/mm/yyyy)

Total Weight Harvested (pounds)

Price Per Pound

Total Dollar Value

4. SIGNATURE
SIGNATURE

PRINTED NAME

POSITION IN COMPANY

DATE