Application for emergency medical transfer of IFQ

Revised: 06/30/2011

OMB No. 0648-0272
Expiration Date: 10/31/2011

U.S. Dept. of Commerce/NOAA
National Marine Fisheries Service
Restricted Access Management
P.O. Box 21668
Juneau, AK 99802-1668
(800) 304-4846 toll free / 586-7202 in Juneau
(907) 586-7354 fax

APPLICATION FOR
EMERGENCY MEDICAL
TRANSFER (EMT) OF IFQ

NOTE: A separate application must be submitted for each IFQ Emergency Medical Transfer.
Emergency Medical Transfers remain in effect only for the calendar year of the transfer.
BLOCK A
Does the Transferor (Medical Condition) qualify for a hired master exception under 50 CFR 679.42(i)(1)? YES [ ] NO [ ]
Does the Transferee (No Medical Condition) hold a Transfer Eligibility Certificate (TEC)?

YES [ ] NO [ ]

BLOCK B – ATTACHMENTS
Use this list to ensure your application is complete.
Incomplete applications will not be processed. NOTE: faxed applications are not acceptable. Please submit originals.

[ ]

Completed, signed, and notarized application

[ ]

Copy of permit or QS Certificate

[ ]

Declaration from certified medical professional
BLOCK C – TRANSFEROR INFORMATION (MEDICAL CONDITION)
2. NMFS Person ID:

1. Name:

3. Date of Birth:

4. Permanent Business Mailing Address:

5. Temporary Business Mailing Address (see
instructions):

6. Business Telephone No.:

7. Business Fax No.:

8. e-mail Address (if any):

Application for Emergency Medical Transfer of IFQ
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.

BLOCK D – TRANSFEREE (NO MEDICAL CONDITION)
1. Name:

2. NMFS Person ID:
3. Date of Birth:

4. Permanent Business Mailing Address:

6. Business Telephone No.:

5. Temporary Business Mailing Address (see instructions):

7. Business Fax No.:

8. E-mail Address (if any)

BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED
1. Halibut [ ] or Sablefish [ ]

2. IFQ Regulatory Area:

3. Number of Units:

4. Numbered To and From (Serial Numbers are shown on the QS Certificate):

5. Actual Number of IFQ Pounds:

6. Transferor IFQ Permit Number:

7. Fishing Year: 20______

REQUIRED SUPPLEMENTAL INFORMATION
YOUR APPLICATION WILL NOT BE PROCESSED UNLESS YOU PROVIDE THE FOLLOWING INFORMATION

BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION
1. Give the price per pound (including leases) $ ___________________/pound of IFQ (Price divided by IFQ pounds)
Including fees
2. What is the total amount being paid for the IFQ in this transaction, including all fees? ______________________

Application for Emergency Medical Transfer of IFQ
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BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION
1. What is the primary source of financing for this transfer (check one)?
[

] Personal resources (cash)

[

] AK Com. Fish & Ag. Bank

[

] Received as a gift

[

] Private bank/credit union

[

] Transferor/seller

[

] NMFS loan program

[

] Alaska Dept. Of Commerce [

] Processor/fishing company

[

] Other (explain)

2. How was the IFQ located (check all that apply)?
[

] Relative

[

] Advertisement/public notice

[

] Broker

[

] Personal friend

[

] Casual acquaintance

[

] Other (explain)

3. What is the Transferee's relationship to the IFQ Holder (check all that apply)?
[

] No relationship

[

] Relative

[ ] Business partner

[

] Friend

[

] Family member

[

Application for Emergency Medical Transfer of IFQ
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] Other (explain)

BLOCK H – MEDICAL DECLARATION
(to be completed by licensed medical doctor, advanced nurse practitioner, or primary community health aid)
1. Name of Treating Medical Professional:

2. Business Telephone Number:

3. Permanent Business Mailing Address:

4. Type of Medical Professional:
[ ] Licensed Medical Doctor
[ ] Advanced Nurse Practitioner
[ ] Primary Community Health Aide

5. Description of the medical condition affecting the applicant or applicant’s family member (attach documentation of
the medical condition and a description of the care required):

I acknowledge the requirements for receiving an Emergency Medical Transfer and certify that, to the best of my
knowledge and belief, the information presented here is true, correct, and complete. The medical condition
described above would prevent the applicant from participating in the IFQ fishery or, in the case of a family
member, require continuous care that would preclude the applicant’s participation in the IFQ fishery.
6. Signature of Treating Medical Professional:

7. Date:

NOTE: This application for transfer must be completed, signed, and notarized by both parties. Failure to
have signatures properly notarized will result in delays in the processing of this application.

Application for Emergency Medical Transfer of IFQ
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BLOCK I –CERTIFICATION OF TRANSFEROR
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the
information presented here is true, correct, and complete.
1. Signature of Transferor (Seller) or Authorized Agent:

2. Date:

3. Printed Name Transferor (Seller) or Authorized Agent Note: If agent, attach authorization:

4. Notary Public Signature:

ATTEST

5. Affix Notary Stamp or Seal Here:

6. Commission Expires:

BLOCK J – CERTIFICATION OF TRANSFEREE (BUYER)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the
information presented here is true, correct, and complete.
1. Signature Transferee (Buyer) or Authorized Agent:

2. Date:

3. Printed Name Transferee (Buyer) or Authorized Agent Note: If agent, attach authorization:

4. Notary Public Signature:

ATTEST

5. Affix Notary Stamp or Seal Here:

5. Commission Expires:

Application for Emergency Medical Transfer of IFQ
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INSTRUCTIONS:
Application for
Emergency Medical Transfer (EMT) of IFQ
The requirement of 50 CFR part 679.41(c) for an individual IFQ permit holder to be aboard the vessel during fishing
operations and to sign the IFQ landing report may be waived as described at 50 CFR part 679.41(d). An emergency
medical transfer (EMT) may be approved if the applicant demonstrates that he or she is unable to participate in the IFQ
fishery for which he or she holds IFQ:
♦

Because of a severe medical condition that precludes participation; or

♦ Because of a severe medical condition involving an immediate family member that requires the IFQ holder’s full
time attendance.

Eligibility. To be eligible to receive an EMT, an individual halibut or sablefish QS holder:
Must possess one or more catcher vessel IFQ permits.
Must not qualify for a hired master exception.
Note: A Separate Application must be submitted for each Emergency Medical Transfer of IFQ.
Please allow at least ten working days for your application to be processed. Items will be sent by first class mail, unless
you provide alternate instructions and include a prepaid mailer with appropriate postage or corporate account number for
express delivery.
If you need assistance in completing this application or need additional information, call Restricted Access Management
at (800) 304-4846 (#2) or (907) 586-7202 (#2).
When completed, mail or deliver the application to
NMFS Alaska Region
Restricted Access Management (RAM)
P.O. Box 21668
Juneau, AK 99802-1668
or
709 West 9th Street, Room 713
Note: It is important that all blocks are completed and all necessary documents are attached. Failure to answer any of
the questions, provide attachments, or to have signatures notarized could result in delays in the processing of your
application.
COMPLETING THE APPLICATION
BLOCK A
Does the Transferor (Medical Condition) qualify for a hired master exception under 50 CFR 679.42(i)(1)?
50 CFR §679.42(i) provides that individuals initially issued QS may hire a master to harvest their annual IFQ on a vessel
that the QS holder has at least a 20% ownership interest in (see regulations for exceptions). If the transferor is a person
who may hire a master to harvest their annual IFQ, the transferor is ineligible to receive an EMT. If you check “Yes,” the
submitted EMT application will be denied.
Application for Emergency Medical Transfer of IFQ
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Does the Transferee (No Medical Condition) hold a Transfer Eligibility Certificate (TEC)?
Only a person that received QS as an Initial Issuee or that holds a Transfer Eligibility Certificate (TEC) is eligible to
receive QS/IFQ by transfer. If you answer "No," the transferee (buyer) will need to contact RAM for instructions on
eligibility procedures and a TEC application form.
BLOCK B – ATTACHMENTS
Use this list as a guide to make sure you have included all the necessary items in the mailing of your application. This will
ensure timely processing of your transfer application. You must attach the completed Medical Declaration and a copy of
the IFQ permit or QS certificate to be considered for an Emergency Medical Transfer.
BLOCK C -- TRANSFEROR (MEDICAL CONDITION)
1.

Name: Full name as it appears on QS Certificate and/or Transfer Eligibility Certificate (TEC).

2.

NMFS Person ID: As found on QS Certificate or TEC.

3.

Date of Birth: Birth date of the person.

4.

Permanent Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.

5.

Temporary Business Mailing Address: Address you want the transfer documentation sent if some-where
other than to the permanent address. Include street or P.O. Box number, city, state, and zip code.

6-8 Business Telephone and Fax Numbers (Include the area codes), and E-mail Address (if any).
BLOCK D -- TRANSFEREE (NO MEDICAL CONDITION)
2.

Name: Full name as it appears on QS Certificate and/or Transfer Eligibility Certificate (TEC).

2.

NMFS Person ID: As found on QS Certificate or TEC.

3.

Date of Birth: Birth date of the person.

4.

Permanent Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.

5.

Temporary Business Mailing Address: Address you want the transfer documentation sent if somewhere other than to the permanent address. Include street or P.O. Box number, city, state, and zip
code.

6-8 Business Telephone and Fax Numbers (Include the area codes), and E-mail Address (if any).

BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED
1. Indicate whether halibut or Sablefish IFQ.
2.

IFQ Regulatory Area:

3.

Number of Units:
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4.

Range of serial numbers for IFQ to be transferred, numbered To and From (Serial Numbers are shown on
the QS Certificate):

5. Actual Number of IFQ Pounds to be transferred
6. Transferor (Seller) IFQ Permit Number
7.

Indicate Fishing Year

BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION
1.

The price per pound of IFQ must be entered for IFQs that are being transferred under an EMT. (To derive
the number of dollars per unit of QS or pound of IFQ, divide the total amount paid, including fees, by the
number of QS units or the number of IFQ pounds being transferred.)

2.

The total amount entered should include any and all monies collected on behalf of the seller for the
shares involved, including any fees that will be paid out to other parties for the expenses of brokering
or assisting in the sale of these shares.

BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION
1.

Indicate the primary source of financing for this transfer (check one).

2.

Indicate how the IFQ was located (check all that apply).

3.

Indicate Buyer's relationship to the IFQ Holder (check all that apply).

BLOCK H -- MEDICAL DECLARATION
(Completed by licensed medical doctor, advanced nurse practitioner, or primary community health aide)
1-3. The medical professional who conducted the medical examination must print or type their name, business
telephone number, and permanent business mailing address.
4.

The medical professional who conducted the medical examination must check the box indicating
the medical category they fall within.

5.

The medical professional conducting the medical examination must provide a concise description of the
medical condition affecting the applicant or the applicant’s family member including verification that the
applicant is unable to participate in the IFQ fishery for which he or she holds IFQ permits during the IFQ
season because of the medical condition and, for an affected family member, a description of the care
required. The medical professional may attach the original medical report or additional information
if necessary.

6.

The medical professional who conducted the medical examination must sign and date the declaration.

BLOCK I - CERTIFICATION OF TRANSFEROR
1.

Sign and print your name and date the application. If completed by a representative, attach authorization..
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2.

A Notary Public must Attest, affix Notary Stamp, and provide date commission expires. The Notary Public
cannot be the person(s) submitting this application.

BLOCK J - CERTIFICATION OF TRANSFEREE
1.

Sign and print your name and date the application. If completed by a representative, attach authorization..

2.

A Notary Public must Attest, affix Notary Stamp, and provide date commission expires. The Notary Public
cannot be the person(s) submitting this application.

___________________________________________________________________________________________
REPORTING BURDEN STATEMENT
Public reporting for this collection of information is estimated to average 2 hours per response, including the time for
reviewing the instructions, searching the 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 Assistant Regional Administrator, Sustainable
Fisheries Division, NOAA National Marine Fisheries Service, P.O. Box 21668, Juneau, AK 99802-1668.
ADDITIONAL INFORMATION
Before completing this form please note the following: 1) Notwithstanding any other provision of 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; 2) This information is mandatory and is required to manage commercial fishing efforts under 50 CFR part
679 and under section 402(a) of the Magnuson-Stevens Act (16 U.S.C. 1801, et seq.); 3) Responses to this information
request are confidential under section 402(b) of the Magnuson-Stevens Act). They are also confidential under NOAA
Administrative Order 216-100, which sets forth procedures to protect confidentiality of fishery statistics.
____________________________________________________________________________________________________

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