Form 3-2405 Visitor Check-In Permit and Use Report

Self-Clearing Check-In Permit

OMB Control No. 1018-XXXX
Expires XX/XX/XXXX

You must complete the Check-In portion of this daily permit and put it
in the permit box before engaging in any activity on the Refuge.

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U. S. Fish and Wildlife Service
(Refuge will insert refuge name)
Each user must carry the Daily Visitor Registration portion while on
the Refuge. At the conclusion of your visit, complete the following
information and put this portion in the permit box.
Number of hours spent on Refuge____
Hunter Harvest Information: (Please check all that apply)
Did you harvest any wildlife? Yes No Example 3Squirrel 3
Game Species
(Each Refuge will list relevant species with a space for the number
harvested and other relevant data required)
Incidental Species
(Each Refuge will list relevant incidental species and other relevant
data required.)
Method:
(Each Refuge will list allowable methods of harvest)
Angler Harvest information:
(Each Refuge will list relevant species and other relevant data
required)
Notice

In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork
Reduction Act (44 U.S. C. 3501), please note the following information:
1. The issuance of a permit and collection of fees on lands of the National
Wildlife Refuge System is authorized by the National Wildlife Refuge
System Administration Act (16 U.S. C. 668dd-ee) as amended, and the
Refuge Recreation Act (16 U.S. C. 460k-460k-4). 2. This information is
required in order to obtain or retain a benefit. We collect this information
to evaluate the qualifications, determine eligibility, and document permit
applicants under the above Acts. It is our policy not to use your name for
any other purpose. The information is maintained in accordance with the
Privacy Act. All information you provide will be considered in reviewing this
application. False, fictitious, or fraudulent statements or representations
made in the application may be grounds for revocation of the permit and may
be punishable by fine or imprisonment (18 U.S.C. 1001). Failure to provide
all required information is sufficient cause for the U.S. Fish and Wildlife
Service to deny a permit. 3. We estimate the public reporting burden on the
applicant for information collection to be 5 minutes. This burden estimate
includes time for reviewing instructions, gathering and maintaining data and
completing and reviewing the form. You may direct comments regarding the
burden estimate or any other aspect of the form to the Service Information
Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop 2042-PDM, U.S.
Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
4. Routine use disclosures may be made: (a)to the U.S. Department of
Justice when related to litigation or anticipated litigation; (b) of information
indicating a violation or potential violation of a statute, rule, order, or license
to appropriate Federal, State, local or foreign agencies responsible for
investigating or prosecuting the violation or for enforcing or implementing
the statute, rule, regulations, order, or license; (c) from the record of the
individual in response to an inquiry from a Congressional office made at the
request of the individual (42 FR 19083; April 11, 1977); and (d) to provide
addresses obtained from the Internal Revenue Service to debt collection
agencies for purposes of locating a debtor to collect or compromise a Federal
Claim against the debtor, or to consumer reporting agencies to prepare
a commercial credit report for use by the Department (48 FR 54716;
December 6, 1983). 5. An agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it displays a
currently valid OMB control number.

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Self-Clearing Daily Vehicle Permit
Each user must enter the date and, while on the
Refuge, display this tag in the vehicle in clear view.

VEHICLE TAG
Other Side Face-up

FWS Form 3-2405
08/12

U. S. Fish and Wildlife Service
OMB Control No. 1018-XXXX
(Refuge will insert refuge name here)
Expires XX/XX/XXXX
Self-Clearing Check-In Permit
Daily Permit
Check in Date:______________ (pre-coded) Permit #__________
Name:_____________________Ph#:_________Cel#:___________
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Self-Clearing Daily Visitor Registration Permit
Each user must complete the following information and carry this
portion while on the Refuge. At the conclusion of your visit, complete
the information on the reverse side and put this portion in the permit
box.
Date ______________________(pre-coded) Permit #__________
Name__________________________________________________
City ___________________________State____________________
Zip Code_______________________________________________
Purpose of Visit: (Please check all that apply)
Hunting
Birding
Wildlife Observation

Photography
Auto Touring
Fishing
Hiking

Boating/Canoeing
Visitor Center
Special Event
Environmental Education Class
Volunteering
Other Recreation (please specify):__________________________
________________________________________________________
________________________________________________________
Refuge unit visited:_______________________________

(Refuge will insert a map of the refuge)

Comments:______________________________________________
_______________________________________________________
_______________________________________________________

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Self-Clearing Daily Vehicle Permit
Date__________________ (pre-coded) Permit #_______________

If there is more than one person in the vehicle, there must be a tag for
each user displayed in the vehicle in clear view.

FWS Form 3-2405
08/12