Form 3-200-10a Federal Fish and Wildlife Permit Application Form

OMB Control No. 1018-0022
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Department of the Interior
U.S. Fish and Wildlife Service
Federal Fish and Wildlife Permit Application Form

Return to: U.S. Fish and Wildlife Service (USFWS)
or

Type of Activity: Special Purpose – Salvage
_____ New Application
_____ Requesting Renewal or Amendment of Permit # __________________

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.
See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.

A.

Complete if applying as an individual

1.a. Last name

1.b. First name

1.c. Middle name or initial

1.d. Suffix

2. Date of birth (mm/dd/yyyy)

3. Social Security No.

4. Occupation

5. Affiliation/ Doing business as (see instructions)

6.a. Telephone number

6.b. Alternate telephone number

6.c. Fax number

6.d. E-mail address

B.

Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution

1.a. Name of business, agency, Tribe, or institution

1.b. Doing business as (dba)

2. Tax identification no.

3. Description of business, agency, or institution

4.a. Principal officer Last name

4.b. Principal officer First name

5. Principal officer title

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact name

7.a. Business telephone number

7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)

1.b. City

1.c. State

1.d. Zip code/Postal code:

1.e. County/Province

1.f. Country

2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)

2.b. City

2.c. State

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

D.

All applicants MUST complete

1.

Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $75.00 nonrefundable processing fee. Federal, Tribal,
State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee – attach documentation of fee exempt status
as outlined in instructions. (50 CFR 13.11(d))
Do you currently have or have you ever had any Federal Fish and Wildlife permits?
Yes 
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: ____________________
No 

2.
3.

Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and the other
applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and accurate to the
best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.
______________________________________________________________________________________________________________________
Signature (in blue ink) of applicant/person responsible for permit (No photocopied or stamped signatures)
Date of signature (mm/dd/yyyy)

Please continue to next page

Form 3-200-10a

Rev. 12/2013

Page 1of 5

SECTION E.
SPECIAL PURPOSE – SALVAGE
(Migratory Bird Treaty Act, 50 CFR 21.27)
Note: A Federal Special Purpose Salvage Permit is required to salvage migratory birds that you find dead and had no part in killing.
The permit authorizes temporary possession of the dead specimens for transport to a designated public, scientific, or educational
institution. Possession for personal use is prohibited. You must be at least 18 years old to apply. Please read “What You Should
Know About a Migratory Bird Special Purpose Salvage Permit” and the pertinent regulations before you sign and submit your
application.
Please provide the following information in the space provided or numbered according to the questions below on a separate sheet of
paper. You should be as thorough and specific as possible in your responses. Incomplete applications will be returned,

delayed or abandoned.
1.

Describe the project or activity for which you require this permit, including the location or area where you propose to salvage.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2.

Identify the public, scientific, or educational institution where the migratory birds salvaged under this permit will be deposited. If
the specimens will be deposited with an institution other than your own, attach a letter, on the institution’s letterhead, from the
Director or Principal Officer of the institution where the salvaged materials will be deposited. The letter must confirm the
institution’s need for the specimens, that they want you to salvage for them, and describe how they will be used.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3.

Anyone who will be assisting you with the permitted activities or acting as your agent must either have their own Federal migratory
bird permit for the activity or be identified by you, in writing, as a subpermittee under your permit. They may also require a State
permit. Subpermittees must be at least 18 years old. As the primary permittee, you will be responsible for ensuring that your
subpermittees are properly trained and adhere to the terms of your permit. Provide the name of anyone besides yourself who will
be conducting activities under your permit.
_____________________________________________________________________________________________
_____________________________________________________________________________________________

4.

You must retain records relating to the activities conducted under your permit for at least 5 years after the date of expiration of your
permit. Is the physical address you provided in Section C on page 1 of this application the address where your records will be kept?
 Yes
 No If “no”, provide the physical address.
_____________________________________________________________________________________________

5.

Any permit issued as a result of this application is not valid unless you also have any required State or tribal permits or
approvals associated with the activity. Have you obtained all required State or tribal permits or approvals to conduct this
activity?
 Yes

6.

If “yes”, attach a copy of the approval(s).

 Have applied (Send copy when issued)

 None required

Disqualification factor. A conviction, or entry of a plea of guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory
Bird Treaty Act, or the Bald and Golden Eagle Protection Act disqualifies any such person from receiving or exercising the privileges of a
permit, unless such disqualification has been expressly waived by the Service Director in response to a written petition. (50 CFR 13.21(c))
Have you or any of the owners of the business, if applying as a business, been convicted, or entered a plea of guilty or nolo contendere,
forfeited collateral, or are currently under charges for any violations of the laws mentioned above?
 Yes
 No
If you answered “Yes” provide: a) the individual’s name, b) date of charge, c) charge(s), d) location of incident, e)
court, and f) action taken for each violation

Form 3-200-10a

Rev. 12/2013

Page 2 of 5

PERMIT APPLICATION FORM INSTRUCTIONS
The following instructions pertain to an application for a U.S. Fish and Wildlife Service or CITES permit. The General Permit Procedures in 50 CFR 13 address
the permitting process. For simplicity, all licenses, permits, registrations, and certificates are referred to as a permit.
GENERAL INSTRUCTIONS:
•
Complete all blocks/lines/questions in Sections A or B, and C, D, and E.
•
An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate
application form for the proposed activity.
•
Print clearly or type in the information. Illegible applications may cause delays.
•
Sign the application in blue ink. Faxes or copies of the original signature will not be accepted.
•
Mail the original application to the address at the top of page one of the application or if applicable on the attached address list.
•
Keep a copy of your completed application.
•
Please plan ahead. Allow at least 60 days for your application to be processed. Some applications may take longer than 90 days to process.
(50 CFR 13.11)
•
Applications are processed in the order they are received.
•
Additional forms and instructions are available from http://permits.fws.gov.
COMPLETE EITHER SECTION A OR SECTION B:
Section A. Complete if applying as an individual:
•
Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the
applicant. Fax and e-mail are not required if not available.
•
If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be
included with the application.
•
Affiliation/ Doing business as (dba): business, agency, organizational, or institutional affiliation directly related to the activity requested in the
application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division of Management Authority
(DMA) will not accept doing business as affiliations for individuals.
Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:
•
Enter the complete name of the business, agency, Tribe, or institution that will be the permittee if a permit is issued. Give a brief description of the
type of business the applicant is engaged in. Provide contact phone number(s) of the business.
•
Principal Officer is the person in charge of the listed business, corporation, public agency, Tribe, or institution. The principal officer is the person
responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at
the business, corporation, public agency, Tribe, or institution who will be available to answer questions about the application or permitted activities.
Often this is the preparer of the application.
ALL APPLICANTS COMPLETE SECTION C:
•
For all applications submitted to the Division of Management Authority (DMA) a physical U.S. address is required. Province and Country blocks are
provided for those USFWS programs which use foreign addresses and are not required by DMA.
•
Mailing address is address where communications from USFWS should be mailed if different than applicant’s physical address.
ALL APPLICANTS COMPLETE SECTION D:
Section D.1 Application processing fee:
•
An application processing fee is required at the time of application; unless exempted under 50 CFR13.11(d)(3). The application processing fee is
assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit. Fees will not be refunded for
applications that are approved, abandoned, or denied. We may return fees for withdrawn applications prior to any significant processing
occurring.
•
Documentation of fee exempt status is not required for Federal, Tribal, State, or local government agencies; but must be supplied by those
applicants acting on behalf of such agencies. Those applicants acting on behalf of such agencies must submit a letter on agency letterhead and
signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the
permitted activity for the agency.
Section D.2 Federal Fish and Wildlife permits:
•
List the number(s) of your most current FWS or CITES permit or the number of the most recent permit if none are currently valid. If applying for reissuance of a CITES permit, the original permit must be returned with this application.
Section D.3 CERTIFICATION:
•
The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation
must be included in the application) must sign and date the application in blue ink. This signature binds the applicant to the statement of
certification. This means that you certify that you have read and understand the regulations that apply to the permit. You also certify that everything
included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before
signing.
ALL APPLICANTS MUST COMPLETE SECTION E.

Please continue to next page

Form 3-200-10a

Rev. 12/2013

Page 3 of 5

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT
Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:
1.

The gathering of information on fish and wildlife is authorized by:
(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.html.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;
Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;
Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;
Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org , 50 CFR 23;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
Wildlife Provisions (Import/export/transport), 50 CFR 14.

2.

Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for
permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service
to deny the request. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently
valid OMB control number.

3.

Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972
(16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4.

Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the
disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
a.
b.
c.
d.
e.

f.
g.

h.
i.
j.

Routine disclosure to subject matter experts, and Federal, Tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to
making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records.
Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment
or notice of the decision on a permit application.
Routine disclosure to Federal, Tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied
to assure compliance with all applicable permitting requirements.
Routine disclosure to Captive-bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share
information on the captive breeding of these species.
Routine disclosure to Federal, Tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and
injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking
a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and
injured birds.
Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or
adjudicative or administrative body, under certain circumstances.
Routine disclosure to the appropriate Federal, Tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing,
or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we
need to monitor activities associated with a permit or regulated use.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.
Routine disclosure 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 FWS.

5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth
date, etc.) will be removed prior to any release of the application.
6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant
burden for a Special Purpose – Salvage permit application is 1 hour and 30 minutes for recordkeeping. 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 222, Arlington Square,
U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
Freedom of Information Act – Notice
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any
information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA.
Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be
accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made
available to the public under FOIA [43 CFR 2.26 – 2.33].

Form 3-200-10a

Rev. 12/2013

Page 4 of 5

Migratory Bird Regional Permit
Offices
FWS
REGION

AREA OF
RESPONSIBILITY

MAILING
ADDRESS

CONTACT
INFORMATION

Region 1

Hawaii, Idaho, Oregon,
Washington

911 N.E. 11th Avenue
Portland, OR 97232-4181

Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]

Region 2

Arizona, New Mexico,
Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]

Iowa, Illinois, Indiana,
Minnesota, Missouri,
Michigan, Ohio, Wisconsin

5600 American Blvd. West
Suite 990
Bloomington, MN
55437-1458
(Effective 5/31/2011)

Tel. (612) 713-5436
Fax (612) 713-5393
Email [email protected]

Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana,
Mississippi, North Carolina,
South Carolina, Tennessee,
Virgin Islands, Puerto Rico

P.O. Box 49208
Atlanta, GA 30359

Tel. (404) 679-7070
Fax (404) 679-4180
Email [email protected]

Region 3

Region 4

Connecticut, District of
Columbia, Delaware, Maine,
Maryland, Massachusetts,
New Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Virginia,
Vermont, West Virginia

P.O. Box 779
Hadley, MA 01035-0779

Tel. (413) 253-8643
Fax (413) 253-8424
Email [email protected]

Region 6

Colorado, Kansas, Montana,
North Dakota, Nebraska,
South Dakota, Utah, Wyoming

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]

Region 7

Alaska

1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503

Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]

Region 8

California, Nevada

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
Fax (916) 414-6486
[email protected]

Region 5

Form 3-200-10a

Rev. 12/2013

Page 5 of 5