Form 3-2321 Application/Nomination Form

OMB Control No. 1018-0075
Expires XX/XX/XXXX

Federal Subsistence Regional Advisory Council Membership

APPLICATION/NOMINATION FORM
APPLICANT’S FULL NAME:
MR./MS.: __________________________________________________________________________________
FIRST
MIDDLE
LAST
Full mailing address:

Contact Information:
Home: ( 907)
Work: ( 907)
Fax: ( 907)
E-mail:
Birthdate:

Where is your (or nominee’s) primary place of residence? (Please note that members must reside in
the region they represent.)
PLEASE ANSWER THE FOLLOWING QUESTIONS (ATTACH ADDITIONAL PAGES IF NEEDED):
1) Describe your (or nominee’s) knowledge of fish and wildlife resources in the region.

2) Describe your (or nominee’s) knowledge of subsistence and customary and traditional uses of
resources in the region.

3) Describe your (or nominee’s) knowledge of sport, guided sport, commercial and other uses of fish
and wildlife resources in the region.

FWS Form 3-2321 REV 10/09

4) Do you (or nominee) participate in meetings on fish and wildlife issues (for example, meetings of
State fish and game advisory committees, Federal subsistence regional advisory councils, commercial
or sport hunting or fishing organizations, marine mammal commissions, tribal or corporation resource
use groups, caribou working groups, subsistence resource commissions, coastal resource service areas,
waterfowl conservation committees)? If so, please describe your (or nominee’s) involvement.

5) Have you (or nominee) served in an official capacity on councils, boards, committees, or associations within the past 10 years? If yes, please describe the role you served while working with these
groups (i.e. Chair, Vice Chair, member).

6) The seat you are applying for represents users throughout the region. How would you (or nominee)
find out about fish and wildlife concerns people have and get information back to those people?

7) Do you (or nominee) use Federal lands for hunting, trapping, fishing, guiding or transporting, gathering, teaching of traditional knowledge, or other use of fish and wildlife resources? If yes, please
describe which Federal lands you use:

8) Will you (or nominee) travel to and attend Regional Advisory Council meetings at least two times
each year? (Regional Advisory Council meetings are usually held in October and February. Transportation
and lodging are pre-paid; per diem is provided for food and other expenses.)
Yes _____
No _____
9) Are you (or nominee) willing to attend Federal Subsistence Board meetings occasionally? (Board
meetings are usually held in December or January. Transportation and lodging are pre-paid; per diem is
provided for food and other expenses.)
Yes _____
No _____

10) Regional Council membership should reflect representation of subsistence and commercial/sport
interests. Regional Council seats are designated for both subsistence use and commercial/sport use representatives. You (or nominee) must choose one or the other.
(Check ONE only!)

_____ a. subsistence

_____ b. commercial/sport

If you are nominating the applicant, please provide your name, your title, and your organization.

Your Name and Title

Organization

REFERENCE CONTACTS: Please include three references and their contact information. If you wish, you
may also submit letter(s) of recommendation. Please provide the most current phone numbers available.
Name:
Organization:
Address:
Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Name:
Organization:
Address:

Name:
Organization:
Address:

I certify, to the best of my knowledge, that all statements are correct and complete.
Signature

Date

Please note: All applications must be signed in ink. No application or nomination will be considered complete
without a signature.
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. This information collection is authorized by the Alaska National Interest Lands Conservation Act and
associated regulations. The Federal Subsistence Board will use information that you provide to make recommendations to
the Secretaries of the Interior and Agriculture for appointment of members to the Federal Subsistence Regional Advisory
Councils. It is our policy not to use your name for any other purpose. We will maintain this information in accordance with
the Privacy Act, but may release it under a Freedom of Information Act request (5 U.S.C. 552). Your response is voluntary,
but is required to obtain or retain a benefit. We may not conduct or sponsor and you are not required to respond to an information collection unless it displays a currently valid OMB control number. OMB has approved this information collection
and assigned OMB Control No. 1018-0075. The relevant burden for completing this form is 2 hours. This burden estimate
includes time for reviewing instructions, gathering 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 Collection Clearance Officer, Fish
and Wildlife Service, Mail Stop 2042-PDM, Arlington Square, Department of the Interior, 1849 C Street, NW., Washington D.C. 20240.
OMB Clearance No. 1018-0075