Form 3-200-10b 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: :

Rehabilitation

_____ 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.d. Suffix

6. Primary contact name

7.a. Business telephone number

C.

4.c. Principal officer Middle name/ initial

7.b. Alternate telephone number

Applicant address

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 $ 50.00 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 3-200-10b

Rev. 12/2013

Page 1of 6

SECTION E. REHABILITATION
(Migratory Bird Treaty Act, 50 CFR 21.31)
Note: A Federal Rehabilitation permit is required to acquire, temporarily possess, or transport sick and injured migratory birds, restore them
to health, and release them back to the wild. Birds undergoing rehabilitation may not be displayed to the public. Permits are available to
individuals and organizations with appropriate facilities as described in the NWRA/IWRC Minimum Standards for Wildlife Rehabilitation
and demonstrated experience in rehabilitating migratory birds. You must be at least 18 years old to apply. A rehabilitation permit may be
valid up to 5 years. Please read “What You Should Know About A Migratory Bird Rehabilitation Permit” and the pertinent regulations
before you sign and submit your application.
Please provide the following information. You may use the space provided as well as a separate sheet of paper with your responses numbered
according to the application questions below. You should be as thorough and specific as possible in your responses. Incomplete applications
will be returned, delayed or abandoned.
1.

What groups of species do you intend to rehabilitate?
 Songbirds/Passerines
 Waterfowl
 Marsh Birds
 Wading Birds
 Shorebirds
 Seabirds
 Raptors  Eagles  Other:_____________________________________________________________________________

2.

(a) Describe in detail your experience and training, including the source and the duration, in treating and rehabilitating migratory birds.
List the species you have worked with and the approximate number of hours or years of experience in each of the following areas:
i) handling, capturing, and restraining
ii) transporting
iii) providing daily care and feeding; and
iv) the types of medical treatments provided and management of injuries.
(b) Provide the name, address, and telephone number of the facility where your experience was obtained.

3.

Provide a letter of recommendation from a federally permitted rehabilitator familiar with your training and experience. Also attach a letter
from a federally permitted rehabilitator stating his or her willingness to provide you with assistance. If these are the same individual, a
single letter will suffice.

4.

Describe how birds will be conditioned for release. If you will use creance flying, describe in detail the techniques you will use and your
experience with these techniques. If you propose to use a flight cage and do not own one, provide a letter from a licensed rehabilitator
stating his or her willingness to allow you the use of their enclosure(s).

5.

Describe your rehabilitation facilities for restricted, limited, and unlimited care. Attach photographs and diagrams of your indoor and
outdoor enclosures. Diagrams must include dimensions (width, length, and height) and a description of interior and exterior construction
materials, such as flooring and netting materials. Indicate the species or type of species to be housed in each. If your facilities are not
physically located at the mailing or physical address provided on page 1, section C.1., of this application provide the physical location
(street address or legal description).

6.

Describe the diet you will administer for each group of species you propose to rehabilitate, and indicate your food source.

7.

Provide the name and telephone number of your State Wildlife Law Enforcement contact.

8.

Subpermittees: Please provide the name of anyone who will be responsible for the permitted activities in your absence. Anyone authorized
to conduct permitted activities in your absence must be at least 18 years old. If a subpermittee will be authorized to rehabilitate migratory
birds at a site other than your facility, provide the following information: name; address; age; description of their migratory bird
rehabilitation experience; type of species they will care for; type of care they will provide; diagrams (width, length, and height dimensions)
and, except for persons raising baby passerines, photographs of their facilities. If permitted activities will take place at a location other than
your facility, the facilities at that location must be pre-approved. Any individual(s) regularly transporting birds directly to your facility or
from your facility directly to another facility must either be listed under your permit as a subpermittee or possess their own rehabilitation
permit. As the primary permittee, you are legally responsible for ensuring that your subpermitees, staff, and volunteers adhere to the terms of
your permit when conducting migratory bird rehabilitation activities. Some states may require Federal subpermittees to have their own state
permit.

9. Attach a letter from a licensed veterinarian stating their willingness to work with you by providing any necessary veterinary assistance.
10. You must retain records of each migratory bird you receive for at least 5 years following the end of the calendar year covered by the records.
The records must include the date each bird is received, type of injury or illness, disposition, and date of disposition.
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. _____________________________________________________________
11. 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 If “yes”, attach a copy of the approval(s).
 Have applied (Send copy when issued)
 None required

Form 3-200-10b

Rev. 12/2013

Page 2 of 6

12. If you are operating as a private individual, as opposed to a business or nonprofit organization, indicate if the Service may include your
name, address, and telephone number in a public list of permitted migratory bird rehabilitators?  Yes
 No
 Not Applicable
13. 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 3-200-10b

Rev. 12/2013

Page 3 of 6

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, 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 re-issuance 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 COMPLETE SECTION E.

Please continue to next page
Form 3-200-10b

Rev. 12/2013

Page 4 of 6

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 an 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 Rehabilitation permit application is 7 hours for the application and 5 hours 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 3-200-10b

Rev. 12/2013

Page 5 of 6

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]

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

Region 6

Form 3-200-10b

Rev. 12/2013

Page 6 of 6