Observer/catch monitor provider permit application

OMB Control No. 0648-0619; Expiration Date: 11/30/2014

Section A – Applicant Information
1. Legal Name of Applicant			2. TIN (if business) or DOB (if person)
			3. State Registered In (if business)
4. Business Mailing Address Street or PO Box			5. Business Phone Number ( )
			6. Business Fax Number (optional) ( )
City	State	Zip Code	7. Business Email (optional)
Section B – Endorsement Request [Check one or both]
Observer Endorsement Catch Monitor Endorsement

Observer/Catch Monitor Provider Permit Application Form Pacific Coast Groundfish individual Fishing Quota

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

Section C – Ownership/Employees/Management And Organization Structure
List All Owners of Applicant Entity Below
Name			Date of Birth
1.
2.
3.
4.
5.
6.
List All Current Employees
Name	Date of Birth	Job Title
1.
2.
3.
4.
5
6.
7.
8.
List Board Members (if applicable) below: Name	Date of Birth
Please attach a written narrative that further describes the organization and management structure of the entity applying for this permit.

Section D – Applicant Prior Experience and Qualifications

For the endorsement(s) you are applying for, please describe any prior relevant experience or qualifications the applicant may have that would qualify them for this permit/endorsement. You may use the space provided below to describe experience/qualification or attach to the application a written narrative specific to each endorsement requested. Prior relevant experience includes but is not limited to: recruiting, hiring, deployment, personnel administration and placing/supporting individuals in remote field or marine work environments. Qualification elements may include the knowledge or educational background of owners and employees.

Observer Endorsement:






















Catch Monitor Endorsement:

Section E – Description of Ability to Carryout Required Responsibilities/Duties

For the endorsement(s) you are applying for, please describe your ability to carry out the required responsibilities and duties listed for observers and/or catch monitors as described in regulation. You may use the space provided below to describe experience/qualification or attach to the application a written narrative.

Observer Endorsement: (see responsibilities/duties described for observers on vessels in the shorebased fishery: at 50 CFR 660.140(h); mothership fishery at 50 CFR 660.150(j) and catcher processor fishery at 50 CFR 660.160(g).

Catch Monitor Endorsement: (responsibilities/duties given at 50 CFR 660.17(f)

Section F – Conflict of Interest Certification

Under penalty of perjury, I affirm that all owners, board members, officers and employees of the applicant have no indirect or direct financial interest in commercial fishing, processing, seafood brokerage operations in the United States.

Indicate whether you affirm/do not affirm the statement above by checking the appropriate box below

I AFFIRM [ ]

I Do NOT Affirm [ ]

Section G – Criminal Convictions, Negative Performance Ratings on
Federal Contracts and Decertification Actions

Under penalty of perjury, I affirm that all owners, board members, officers of the applicant have satisfactory performance on any Federal contracts held by the applicant and have not criminal convictions related to: embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement, receiving stolen property or commission of any other crimes of dishonesty as defined by U.S. state or Federal law that would seriously and directly affect the fitness of the applicant.

I also affirm no owners, board members, or officers of the applicant that have been decertified as an observer or catch monitor under provisions in §§ 660.18(e), and 660.140(h)(6), 660.150(j)(6), 660.160(g)(6) or 679.53(c).

Indicate whether you affirm/do not affirm the statement above by checking the appropriate box below

I AFFIRM [ ]

I DO NOT AFFIRM [ ]

Section H – Certification of Applicant and Notary This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative
Notary Public Signature  ATTEST	Affix Notary Stamp or Seal Here
Date Commission Expires
WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil penalty of up to $140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001. PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of this collection. The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065). PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing the 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 aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and released to the public.