Federal Permit/Certificate Application to Fish in Colomb

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

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

FEDERAL PERMIT/CERTIFICATE
APPLICATION TO FISH IN COLOMBIAN
TREATY WATERS

263 13th Avenue South
St. Petersburg, FL 33701
Toll Free 877/376-4877 (8:00 am - 4:30 pm ET)
727/824-5326 (8:00 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

FOR OFFICE USE ONLY
Reviewer's Initials and Date
Sanction Case Number if
Sanctioned
Expiration Date

Application ID

FOR OFFICE USE ONLY

REMEMBER TO SEND A COPY of your current (not expired) United States Coast Guard (USCG) Certificate of Documentation.
If we have a copy of your USCG Certificate of Documentation on file, it must not be expired. Do not send your original. We
cannot accept a bill of sale.

January 1, 2011 - December 31, 2011
1. VESSEL INFORMATION
USCG DOCUMENTATION NUMBER

TOTAL HORSEPOWER

VESSEL NAME

Crew Size - Total number of crew,
Including the Captain

HULL COLOR

SUPERSTRUCTURE COLOR

YEAR BUILT

LENGTH (FEET)

NAME OF COMPANY THAT BUILT THE VESSEL

INTERNATIONAL RADIO CALL SIGN

DO YOU HAVE SAILS?

YES

NO

HOLD or FISH BOX CAPACITY
(Pounds of Harvest) How many pounds of
product can you bring to the dock when full?
HULL MATERIAL

HULL IDENTIFICATION or IMO NUMBER

FUEL DATA

PRODUCT
STORAGE (check
all that apply)

DIESEL
FIBERGLASS

GASOLINE

STEEL

OTHER (DESCRIBE)

HAILING PORT CITY

WOOD
HAILING PORT COUNTY OR PARISH

HAILING PORT STAT
CEMENT

GROSS TONS

NET TONS

OTHER
________________

FUEL CAPACITY TOTAL GALLONS

ON ICE IN HOLD,
FISH BOX, ICE
CHEST, COOLER
ETC.,
FREEZER
LIVE WELL

Form Revision 05/17/2011
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2. VESSEL OWNER AND LESSEE INFORMATION
Copy this page as needed to provide the required information on all persons or businesses that own or lease the vessel listed in Section 1.
1) Please complete the top section of this page for the owner of the vessel as shown on the USCG Certificate of Documentation. If the vessel is jointly
owned, please enter the information for the managing (primary) owner. If the owner is a business, enter the Federal ID number and date the business
was filed with the state. If the owner is an individual, enter the Social Security Number.
2) Complete the bottom section of this page for a joint owner if the vessel is jointly owned by more than one owner, OR if the vessel is leased, for the
entity that is leasing the vessel from the vessel owner. You must submit information on each joint owner and for each lessee. If you need more spaces
for additional owners or lessees, copy the blank form or provide the required information on a separate sheet of paper.
3) Place an "X" in the Mailing Recipient block to indicate who will receive the permit and all related information, usually the managing owner if the vessel
is jointly owner. Please only mark one box.

Vessel Owner as shown on the USCG Certificate of Documentation,
This section is required for all applications.

Check one

INDIVIDUAL or SOLE PROPRIETORSHIP

JOINT OWNERSHIP

PARTNERSHIP

CORPORATION

OTHER ____________

Mailing Recipient - Mark this box if you want this entity to receive all mail concerning this permit; mark only one person
Mr/Mrs/Ms

Last Name or Name of Business

First Name

Suffix JR,SR,etc.

Middle Name

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

Tax ID # (Federal Tax ID or SSN)

Date of Birth or Date Business Filed (MM/DD/YYYY)

Area Code

Phone Number

Second Vessel Owner as shown on the USCG Certificate of Documentation, or Vessel Lessee.
This section is required only if the vessel is jointly owned and/or if the vessel is leased from the owner.
Photocopy this page if more room is needed.
This entity is a vessel OWNER
Check one

or vessel LESSEE

INDIVIDUAL or SOLE PROPRIETORSHIP

(For lessees only) LEASE START DATE:
JOINT OWNERSHIP

LEASE EXPIRATION DATE:

PARTNERSHIP

CORPORATION

OTHER ____________

Mailing Recipient - Mark this box if you want this entity to receive all mail concerning this permit; mark only one person
Mr/Mrs/Ms

Last Name or Name of Business

First Name

Middle Name

Suffix JR,SR,etc.

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

Tax ID # (Federal Tax ID or SSN)

Date of Birth or Date Business Filed (MM/DD/YYYY)

Area Code

Phone Number

REMINDER: THE APPLICANT MUST SIGN THE APPLICATION IN THE SIGNATURE SECTION ON PAGE 4
Page 2

3. OFFICER/SHAREHOLDER INFORMATION FOR ENTITIES THAT OWN OR LEASE THE VESSEL
This page must be filled out if a company/business is listed as the owner or the lessee of the vessel in Section 2.
Copy this page as needed to provide information on all persons that are officers/shareholders of the business/company shown in Section 2.
If this vessel is owned or leased by a business, then complete this section for each officer or partner associated with the business. You must provide the
information for all officers that are shown on your most recent annual report. If your business is structured as a corporation, you are required to identify all
shareholders in the corporation that own at least 1% of the shares, as well as the percentage of all shares in the corporation held by each shareholder.
Please mark the box indicating there are Minor Shareholders if you have shareholders that individually hold less than 1% of the shares of the company.The
total of all entries must be 100 percent unless you have minor shareholders.

Owner or lessee of the vessel:

Owner

Lessee

Business name:

Federal Tax ID #

All individuals associated with the above-named vessel owner or lessee must be included in this application. Photocopy this page or attach additional sheets
as necessary to list all officers, directors, shareholders, and registered agents of the business. Provide their name, Social Security Number, address, phone
number, date of birth, and position held in business.
Position held - check ALL that apply
President/CEO

Vice President

Secretary

Treasurer

Director/Manager

Shareholder

Other

Percent (%) of Corporation Held

Mr/Mrs/Ms

Last Name

First Name

Suffix - Jr,Sr,etc

Middle Name

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

Area Code

Date of Birth (MM/DD/YYYY)

SSN

Phone Number

Position held - check ALL that apply
President/CEO

Vice President

Secretary

Treasurer

Director/Manager

Shareholder

Other

Percent (%) of Corporation Held

Mr/Mrs/Ms

Last Name

First Name

Suffix - Jr,Sr,etc

Middle Name

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

SSN

Area Code

Date of Birth (MM/DD/YYYY)

Phone Number

MINOR SHAREHOLDERS - Check here if one or more of shareholders individually holds shares that is less than 1% of the total shares of the company.
TOTAL PERCENTAGE (%) of Company held by Minor Shareholder(s)

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SECTION 4. ADDITIONAL INFORMATION
PRINCIPAL PORT OF LANDING OF THE FISH TO BE TAKEN FROM COLOMBIAN TREATY WATERS:

PRIMARY SPECIES OF FISH TO BE TAKEN FROM COLOMBIAN TREATY WATERS:

PRIMARY GEAR TO BE USED IN COLOMBIAN TREATY WATERS:

5. SIGNATURE FOR APPLICATION - REQUIRED
The undersigned certifies under penalty of perjury that the foregoing information is true and correct (28 USC 1746; 18 USC 1621; 18 USC 1001,
16 USC 1857).
Please note: If the vessel listed in Section 1 is leased, the applicant who signs below must be an individual named as a lessee in Section 2, or an officer or
shareholder of the lessee as listed in Section 3. If the vessel listed in Section 1 is not leased, the applicant must be an individual named as an owner in
Section 2, or an officer or shareholder of the owner as listed in Section 3.

Applicant Signature

Position in Company

Date

Print Name

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing 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 suggestions for reducing this burden to: PRA Officer, National Marine Fisheries Service, F/SER2, 263 13th
Avenue South, St. Petersburg, FL 33701.
The National Marine Fisheries Service requires this information for the conservation and management of marine fishery resources. The data reported will be
used to develop, implement, and monitor fishery management activities for a variety of other uses. Responses to this collection are required to obtain or
retain a fisheries permit under the Magnuson - Stevens Act. Name and address information will be released via a NOAA website. All other data submitted
will be handled as confidential material in accordance with NOAA Administrative Order 216-100, Protection of Confidential Fishery Statistics.
Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected 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
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