Federal Fisheries Application for Vessels Fishing for Wr

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

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

FEDERAL PERMIT APPLICATION FOR
VESSELS FISHING FOR WRECKFISH
OFF THE SOUTH ATLANTIC STATES

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)

FOR OFFICE USE ONLY

http://sero.nmfs.noaa.gov

Reviewer's Initials and Date
Permit Check or Money Order
Number and Amount
Sanction Case Number if
Sanctioned
Non Compliance Hold Date
Non Compliance Cleared Date

Application ID

PERMIT NUMBER
Expiration Date

FOR OFFICE USE ONLY

REMEMBER TO SEND A COPY of your current (not expired) United States Coast Guard (USCG) Certificate of Documentation.
If this vessel is not documented, send a copy of your state vessel registration. If we have a copy of your documentaion or
state registration on file, it must not be expired. Do not send your original. We cannot accept a bill of sale. If your vessel's
state registration does not list all owners of the vessel, also provide a copy of the vessel's title, or other documentation from
the appropriate state agency that identifies all vessel owners.
- Please provide the following required information.
- The applicaiton fee is $50.00, replacement fee is $18.00. Fees are payable as Check or Money Order made out to the
U.S. Treasury.

April 16, 2011- January 14, 2012
1. VESSEL INFORMATION
OFFICIAL NUMBER FROM USCG CERTIFICATE OF
DOCUMENTATION (if the vessel is documented)

YEAR BUILT

STATE REGISTRATION NUMBER (as applicable)

Crew Size - Including the Captain

VESSEL NAME

LENGTH (FEET)

HOLD or FISH BOX CAPACITY
(Pounds of Harvest)

HULL IDENTIFICATION or IMO NUMBER

HULL MATERIAL

FUEL DATA
DIESEL

HAILING PORT CITY

HAILING PORT COUNTY OR PARISH

HAILING PORT STAT

FIBERGLASS

GASOLINE

STEEL

OTHER (DESCRIBE)

WOOD
CEMENT

USCG DOCUMENTED VESSELS ONLY
GROSS TONS

TOTAL HORSEPOWER

NET TONS

OTHER
________________

FUEL CAPACITY TOTAL GALLONS

PRODUCT
STORAGE (check
all that apply)

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

Page 1
Form Revision 05/19/2011

2. VESSEL OWNER AND/OR LESSEE INFORMATION
1) Please complete Section 2 on this page for the owner of the vessel (that issued to fish for wreckfish to be sold on this certificate) as shown on the
USCG Certificate of Documentation or, if not documented, on the state registration certificate. 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. If the owner is an individual,
enter the Social Security Number.
2) Complete the bottom part of Section 2 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 this page blank first or provide the required information on a separate sheet of paper.
3) If your vessel's state registration does not list all owners of the vessel, also provide a copy of the vessel's title, or other documentation from the
appropriate state agency that identifies all vessel owners.

Vessel Owner as shown on the USCG Certificate of Documentation, or for undocumented vessels, the State Registration.
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 State Registration, 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.
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

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

Page 2

Area Code

Phone Number

1) Please complete section 3 on this page for the Wreckfish Shareholder. If the Wreckfish Shareholder is a business, enter the Federal ID number and
date the business was filed. If the owner is an individual, enter the Social Security Number and date of birth.
2) Complete the bottom part of section 3 for a joint shareholder owner if the shares are jointly held by more than one person.

3. WRECKFISH SHAREHOLDER INFORMATION
Shareholder's Certificate Number

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

Second Wreckfish Shareholder
Shareholder's Certificate Number

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

Page 3

Area Code

Phone Number

4. OFFICER/SHAREHOLDER INFORMATION FOR WRECKFISH SHAREHOLDERS
Please copy this page as needed to provide information on all persons or businesses that own or lease this vessel.
If this shareholder's certificate is owned 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 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 thshares of the
company. The total of all entries must be 100 percent unless you have minor shareholders.

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 Numbers,
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

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

Date of Birth

Tax ID # (SSN)

Area Code

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

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 # (SSN)

Date of Birth

Area Code

Phone Number

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

SECTION 5. CERTIFICATION AND SIGNATURE OF APPLICANT. If the wreckfish shareholder is not the vessel
owner, the undersigned certifies and documents that the vessel owner or operator is an employee, contractor or
agent of the shareholder.
Date

Shareholder's
Signature
Print Name
Page 4