Western Pacific Pelagic Squid Jig Permit Application

FEDERAL FISHERIES PERMIT APPLICATION FORM

OMB Control No: 0648-0589
Expires: 08/31/2012

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION
NATIONAL MARINE FISHERIES SERVICE

PACIFIC ISLANDS REGION
Mail or deliver this application to:
NMFS Pacific Islands Regional Office
ATTN: Permits
1601 Kapiolani Blvd., Suite 1110
Honolulu, Hawaii 96814-4733
Tel: (808) 944-2200; FAX: (808) 973-2940

2012

WESTERN PACIFIC PELAGIC SQUID JIG PERMIT
Pelagic Fisheries of the Western Pacific Region

Please Print Legibly. Items marked with * are required. Please fill in other items as completely as possible. Note required documents
at bottom of page.
*VESSEL NAME: ________________________________________ *VESSEL OFFICIAL NO: ________________

(USCG or State number)

*VESSEL LENGTH OVERALL: ____________ (feet)

RADIO CALL SIGN:_______________

*VESSEL OWNER: ____________________________________________________________
First, Middle, & Last Name or Business Name

*DATE OF BIRTH OR INCORPORATION (business): _______________________________

_______________________

Taxpayer Identification Number
(*If a business owns the vessel)

Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize collection of this information. This information is used to verify the identity of the
applicant(s) and to accurately retrieve confidential records related to federal commercial fishery permits. The primary purpose for requesting the TIN is for the
collection and reporting on any delinquent amounts arising of such person’s relationship with the government pursuant to the Debt Collection Improvement Act of 1996
(Public Law 104-134). Personal information is confidential and protected under the Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.

*BUSINESS CONTACT: _________________________________________________________/TITLE: ____________________
(First, Middle, & Last Name, if not same as vessel owner)

*BUSINESS MAILING ADDRESS: ______________________________________
Street/PO Box

(corporate officer, business owner, partner)

_______________
City

______
State

_________
ZIP Code

*BUSINESS PHONE (_____)_____________; CELL PHONE (_____)_____________ FAX (_____)______________
EMAIL: ______________________________________________
*APPLICANT: ___________________________________________________________________ *DATE: ________________
Printed Name and Signature of Person Submitting Application

*APPLICANT TITLE: ± Vessel owner, ± Permit holder, ± Corporate officer or partner, ± Designated agent, or ± Other______________
(Check only one)

*Application is for a new permit? ___ or a renewal? ___
REQUIRED DOCUMENTS: You must submit the following with the application form:
1) A copy of the vessel's current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from a
state/territorial agency (undocumented vessel) showing the current vessel owner,
2) Payment by check for the non-refundable application processing fee of $32.00, payable to Department of Commerce, NOAA, and
3) A signed letter from the permit holder authorizing the applicant as the agent, if the applicant is acting as an agent for the vessel
owner.
It is prohibited to file false information on any application for a fishing permit (50 CFR ' 665.15(b)).

(side two)

OMB Control No: 0648-0589
Expires: 08/31/2012

PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 30 minutes for the WP pelagic squid jig permit application and 2 hours for all
permit denial appeals. Each burden includes 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 aspects of this
collection of information, including suggestions for reducing this burden, to NMFS Pacific Islands Regional Administrator, 1601 Kapiolani Blvd.
Suite 1110, Honolulu, Hawaii 96814-4700.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal
regulations in the Western Pacific Region. This will enable NMFS and the Western Pacific Fishery Management Council to (a) determine who
would be affected by changes in management; (b) inform license holders of changes in fishery regulations; and (c) determine whether the objectives
of the fishery program are being achieved by monitoring entry and exit patterns and other aspects of the fisheries. The information is used in
analyzing and evaluating the potential impacts of regulatory changes on persons in the regulated fisheries as well as in related fisheries. Responses
to the collection are required to obtain the benefit of a license for the fishery involved (ref. 50 CFR 665.13). Data provided concerning the vessel
and/or business of the respondents are handled as confidential under the Magnuson-Stevens Fishery Conservation and Management Act (Sec.
402(b)). Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject 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 Control Number.