Federal Permit Application for an Annual Dealer Permit

OMB No. 0648-0205 Form Approval Expires: 10/31/2014

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

FEDERAL PERMIT APPLICATION FOR AN
ANNUAL DEALER PERMIT

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

FOR OFFICE USE ONLY
Reviewer's Initials and Date
Check or Money Order
Number and Amount
Sanction Case Number if
Sanctioned
SERO Dealer Number
Application ID
Expiration Date

FOR OFFICE USE ONLY

1. DEALER INFORMATION
Dealer entity is (check one):

INDIVIDUAL or SOLE PROPRIETORSHIP

PARTNERSHIP

CORPORATION

OTHER ____________

If the dealer is a partnership, corporation, or other business entity provide the business name, Federal Tax ID number, and date the business was filed.

Name of Partnership, Corporation, or Business

Federal Tax ID Number

Date business was filed
(MM/DD/YYYY)

If the dealer is an Individual or Sole Proprietorship complete the following information - name, Social Security Number (SSN), and date of birth:
Mr/Mrs/Ms

Last Name

Tax ID # (SSN)

First Name

Date of Birth (MM/DD/YYYY)

Middle Name

Area Code

Suffix: JR,SR, etc.

Phone Number

2. DEALER CONTACT INFORMATION

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Area Code

Phone Number

Page 1

Form Revision 01/03/2012

3. Permits
INSTRUCTIONS: Indicate which permit(s) and transaction(s) you are applying for. Find the fishery in the left column and mark the check box beside
that fishery to indicate what transaction you want.
New

Renewal

New

Atlantic Dolphin/Wahoo (DDW)

South Atlantic Wreckfish (WD)

Shark (SK)

South Atlantic Rock Shrimp (RSD)

Domestic Swordfish (SD)

South Atlantic Golden Crab (GCD)

South Atlantic Snapper-Grouper
Excluding Wreckfish (SGD)

Gulf of Mexico Reef Fish (RD)

Renewal

4. COMPANY OFFICER and SHAREHOLDER INFORMATION
Complete this section only if the Dealer listed in Section 1 is a Corporation, Partnership, or other business entity. If the Dealer listed in
Section 1 is an individual or sole proprietorship, skip this section. Please copy this page as needed to provide information on all persons
associated with the Dealer.
Please complete this section for each officer or partner associated by partnership, corporation, or other business relationship to the Dealer listed in
Section 1.
Position held:
President/CEO

Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name

Director/Manager

Agent

First Name

Other

Suffix - Jr,Sr,etc

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Street Address (PO Box not acceptable)

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:
President/CEO

Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name

Director/Manager

Agent

First Name

Other

Suffix - Jr,Sr,etc

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Street Address (PO Box not acceptable)

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)

Page 2

Phone Number

5. RECEIVING FACILITIES
INSTRUCTIONS: List the names and street addresses for all facilities where product is received (fish is off loaded from the fishing vessels). Please copy
this page as needed to provide information on all facilities where fish are received.

Business Name

Street Address (PO Box not acceptable)

Area Code

Apt/Suite #

City

State

Business Name

Street Address (PO Box not acceptable)

City

State

Business Name

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

Apt/Suite #

City

State

Business Name

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

Business Name

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

Business Name

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

Page 3

Zip Code

Country

Zip Code

Country

Zip Code

Country

Phone Number

County/parish

Area Code

Country

Phone Number

County/parish

Area Code

Zip Code

Phone Number

County/parish

Area Code

Country

Phone Number

County/parish

Area Code

Zip Code

Phone Number

County/parish

Area Code

Business Name

Street Address (PO Box not acceptable)

County/parish

Area Code

Apt/Suite #

Phone Number

Zip Code

Country

Phone Number

County/parish

Zip Code

Country

6. State Wholesaler Licenses
Complete the following and provide a copy of each state wholesaler's license held by the dealer.
State Wholesaler
License Number :

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License :

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

State Wholesaler
License Number:

State
Issued By

Other Federal permits or licenses held (issued from a
Federal permit office outside of the Southeast Region).

7. SIGNATURE
The undersigned certifies under penalty of perjury that the foregoing information is true and correct (28 U.S.C. section 1746; 18 U.S.C. section 1621;
18 U.S.C. section 1001).
Please note: The applicant who signs below must be the dealer identified in Section 1 unless the dealer is a partnership, corporation, or other
business entity, in which the applicant must be an individual named as an officer or shareholder of the business as listed in Section 4.

Applicant Signature

Date

Printed Name

Position in Company (if applicable)

Payment Reminder:
All applications must include payment of a non-refundable application fee in the form of a check or money order made
payable to the U.S. Treasury. The fee required is $50.00 for the first fishery and $12.50 for each additional fishery
requested with this application.

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 Control Number.

Page 4

Instructions for the Federal Application for an Annual Dealer
Permit
ACTIVITIES FOR WHICH PERMITS ARE REQUIRED
DOLPHIN/WAHOO

Under 50 CFR 622.4, a dealer who receives Atlantic dolphin/wahoo harvested in the EEZ off the Atlantic
states (Maine through the East Coast of Florida) must obtain an annual dealer permit.

GOLDEN CRAB
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives South Atlantic golden crab harvested in the EEZ off the
Southern Atlantic states must obtain an annual dealer permit.

REEF FISH
(Gulf of Mexico)

Under 50 CFR 622.4, a dealer who receives reef fish harvested from the EEZ of the Gulf of Mexico
must obtain an annual dealer permit.

ROCK SHRIMP
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives rock shrimp harvested in the EEZ off the Southern Atlantic
states must obtain an annual dealer permit.

SNAPPER-GROUPER
(South Atlantic)

Under 50 CFR 622.4, a dealer who receives South Atlantic snapper-grouper, excluding wreckfish,
harvested in the EEZ off the Southern Atlantic states must obtain an annual dealer permit.

SHARK

Under 50 CFR 635.4, a dealer who receives sharks from the Western North Atlantic Ocean including the
Gulf of Mexico and the Caribbean Sea must obtain an annual dealer permit.

SWORDFISH

Under 50 CFR 635.4, a dealer who receives from a U.S. vessel a swordfish harvested from the Atlantic
Ocean or Gulf of Mexico must obtain an annual domestic dealer permit.

WRECKFISH
(South Atlantic)

Under 50 CFR 622.4(a)(4), a dealer who receives a wreckfish harvested from the South Atlantic must
obtain an annual dealer permit.

INSTRUCTIONS
Complete the following sections, as applicable:
SECTION 1 & 2 Print or type the name of the business and address as shown on your business license. If the applicant is a
business, print or type the Federal Tax ID number assigned to your business by the Internal Revenue Service
(taxpayer ID information) if one has been assigned. If applicant is an individual, enter the Social Security Number
(taxpayer ID information).
SECTION 3

Select the fisheries for which you are applying.

SECTION 4

If the application is for a dealer that a corporation, partnership, or other business entity owns, then information on the
dealer’s officers/ shareholders is required. If additional space is needed, please photocopy the blank page as many
times as is necessary to provide information on all officers/shareholders associated with the dealer.

SECTION 5

Complete this section for each physical location where fish are received. Note: A Post Office Box is not acceptable
as a physical location where fish are received.

SECTION 6

Provide the state wholesale license for each state in which the dealer has a facility. Also, please provide the permit
number of any Federal permits issued, for example, a dealer permit issued by the NMFS Northeast Regional Office
(NERO).

SECTION 7

The application must be signed and dated. If the dealer is a corporation, partnership, or other business entity then
the applicant must be an officer or shareholder of the dealer.

UPDATED 10/25/2011

Additional Instructions:
FEE SCHEDULE FOR DEALER PERMITS:
1=$50

2=$62.50

3+$75.00

4=$87.5

5=$100.00

6=$112.50

7=$125.00

8=$137.50

1. Mail the completed application, copy of state wholesaler’s license (if required) for each state in which you operate, and a check or
th
money order made payable to the U.S. TREASURY to: National Marine Fisheries Service (F/SER14), 263 13 Avenue South., St.
Petersburg, FL 33701. Questions may be telephoned to our toll free number at (877) 376-4877 or 727/824-5326 between 8 am 4:30pm ET. If you would like your permit and associated documents returned to you overnight upon completion of processing, enclose
a completed, pre-paid US Postal Service, UPS or Federal Express air bill, complete with your street delivery address (FEDEX and UPS
do not deliver to PO Boxes), telephone number, and for FEDEX or UPS - your FEDEX or UPS account number or major credit card
number with the expiration date. Please note, using the prepaid overnight delivery option does not expedite permit processing, it can
only expedite delivery upon completion of processing.
States required to submit wholesale license: Alabama, California, Florida, Georgia, Hawaii, Louisiana, Massachusetts, Maryland,
Maine, Pennsylvania, Rhode Island, South Carolina, U.S. Virgin Islands and Washington.
2. The application fee is $50 for the first fishery and $12.50 for each additional fishery and is non-refundable. A check or money order
payable to the U.S. TREASURY must accompany each application. The flat rate fee to replace lost or damaged permit(s) is $18.
Complete all lines or sections that apply for the type(s) of fishery(ies) requested. Select only those your business will need. Certain
fisheries require mandatory reporting requirements.
3. Atlantic Shark Dealers must submit a copy of a valid Atlantic shark identification workshop certificate for each place of business
listed on the shark dealer permit. The certificate must be either a SHARK DEALER OWNER - SHARK IDENTIFICATION WORKSHOP
CERTIFICATE or a SHARK DEALER PROXY - SHARK IDENTIFICATION WORKSHOP CERTIFICATE. If you have submitted a copy
of your certificate(s) and it is not expired, you do not have to resubmit the document(s). Important Note – A SHARK DEALER PROXY
CERTIFICATE is only valid for a renewal and will not be accepted for a new permit. For information about Shark Identification
Workshop Schedules, contact (301) 713-2347.
In accordance with Federal regulations, any change in your permit information must be reported to the NMFS Regional
Administrator within 30 days of the change.
KNOWINGLY SUPPLYING FALSE INFORMATION FOR THE PURPOSE OF OBTAINING A DEALER PERMIT IS A VIOLATION OF
FEDERAL LAW PUNISHABLE BY A FINE AND/OR IMPRISONMENT.