Form 3-200-77 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
0B

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

Type of Activity:

Native American Eagle Take

_____ 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

D.
1.

2.
3.

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete
Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount $00.00 (no fee required). 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
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)
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Form 3-200-77

Rev. 12/2013

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E. NATIVE AMERICAN EAGLE TAKE
(Bald and Golden Eagle Protection Act; 50 CFR 22.22)
A Federal Native American Eagle Take permit is required in order to take Bald Eagles or Golden Eagles from the wild for Native
American religious purposes. This permit is intended only for Tribal members conducting a demonstrable historic religious ceremony
that requires take of eagles from the wild. You must be an enrolled member of an Indian tribe that is recognized under the Federally
Recognized Tribal List Act of 1994, 25 U.S.C. 479a-1, 108 Stat. 4791 (1994). You must be at least 18 years of age to apply for a permit.
Your signature on this application affirms that you are requesting an eagle(s) for religious purposes and that your answers to the
questions below are true and accurate to the best of your knowledge and belief.



If you are applying on behalf of a Tribe, please complete section B on page 1 of this form. You must identify a tribal government
official as the Principal Officer, who will be responsible for signing the application and any permitted activities.



If you are applying as an individual, your application must be co-signed on page 1, section D.3. of this form, or otherwise approved
in writing by a tribal government official for your tribe.
Note: Do not use this application if you wish to apply for a permit to obtain eagle parts from the National Eagle Repository. For that
permit, use Form 3-200-15A, Eagle Parts for Native American Religious Purposes Permit Application/First Order. That application is
available at http://www.fws.gov/forms/3-200-15a.pdf.
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Disclaimer: Whereas the U.S. Fish and Wildlife Service (we) will do what we can to protect any information that you identify as confidential
or private under one of the Freedom of Information Act exemptions that may be used to protect information from disclosure (5 U.S.C.
552(b)), we cannot guarantee that we will not ultimately have to disclose the information.
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Please provide the information below in the space provided or numbered according to the questions below on a separate sheet of paper. If
needed, use a separate sheet of paper. If your religion does not permit you to reply to any of the questions below, please provide a signed
statement identifying the particular question or questions at issue and certifying that providing the information requested would
substantially burden the exercise of your religion. If we are unable to adequately evaluate your application on the basis of the information
you provide, further inquiry may be necessary.
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1.

A description of the eagle(s) to be taken from the wild:
a. Species (check one):

b. For each age group, enter the quantity to be taken:

 Bald Eagle
 Golden Eagle

Eggs ________________
Immature _____________

2.

What time of year will the eagle(s) be taken?  Winter

3.

Will the eagle(s) be (check one):

4.

Will live eagles be held in captivity?  No, live eagle(s) will not be held in captivity.
 Yes. If “yes”, how long will they be held in captivity? _______________________
(Live eagles must be held under humane and healthful conditions.)

5.

Will parts from the eagle(s) be retained in your possession a year or more after the eagle(s) is taken from the wild? (If so, we may need
to issue an additional separate lifetime permit for possession of the parts.)  Yes  No

6.

The State, county, and locality (or reservation) where the eagle collection will occur:

 Collected live, or

 Summer

Nestlings _____________
Adult _______________
 Spring

 Fall

 Killed in the wild?

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
7.

The name of your religion: ____________________________________________________________________________

8.

Please explain why take of a live eagle(s) from the wild is necessary and why an eagle carcass, parts, or feathers from another source
will not suffice.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

9.

Name of the tribe of which you are an enrolled member: _____________________________________________________________

Form 3-200-77

Rev. 12/2013

Page 2 of 7

10.

Attach a completed Certification of Enrollment in a federally recognized tribe. (If the permit applicant is a Tribe, the Certification
of Enrollment must be for the Principal Officer.) The certificate must be signed by the tribal official who is authorized to certify
that an individual is a duly enrolled member of that tribe, and must include the official title of that certifying official. A Certification
of Enrollment form is included with this application.

11.

Attach a signed statement of consent from the landowner or managing official responsible for the land where the eagle(s) will be collected.

12.

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.
__________________________________________________________________________________________________________

13.

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

14.

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 3-200-77

Rev. 12/2013

Page 3 of 7

Department of the Interior
U.S. Fish and Wildlife Service
Division of Migratory Birds
Eagle Permit Applicant:
(Please print)
Name: ________________________________________________________________________
Address: ______________________________________________________________________
______________________________________________________________________________
TELEPHONE NUMBER: ____________________________________________________________
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CERTIFICATION OF ENROLLMENT IN A U.S. FEDERALLY RECOGNIZED TRIBE
(By Certifying Tribal Official)
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The U.S. Fish and Wildlife Service administers the Bald and Golden Eagle Protection Act, the
Federal law protecting eagles. This law provides for Native American use of eagle feathers for
religious purposes. Eagles and eagle feathers are accumulated by the Service’s National Eagle
Repository and made available to Native Americans.
Application for a permit to acquire eagle feathers requires certification that the requesting individual
is an enrolled member of an Indian Tribe that is federally recognized under the Federally
Recognized Tribal List Act of 1994, 25 U.S.C. 479a-1, 108 Stat. 4791 (1994). The certificate must
be signed by the Tribal official who is authorized to certify that an individual is a duly enrolled
member of that Tribe, and must include the official title of that certifying official. (50 CFR 22.22)
- - - - - - - - - - - - - - - Name of certifying official (print):
I certify that

is an enrolled member of the
Tribe, Enrollment #

.

I understand that making a false statement can make me subject to the criminal penalties of 18
U.S.C. 1001.
Signature:

Date: __________________

Title:

Office phone no. (

)

-___________

NOTE TO CERTIFYING OFFICIAL: Please expedite this completed Certification of
Enrollment to the applicant at the above address.
APPLICANT: Attach this completed certification to your Native American Eagle Take application
and mail them to the U.S. Fish and Wildlife Service Regional Migratory Bird Permit Office responsible
for your state.

Form 3-200-77

Rev. 12/2013

Page 4 of 7

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.
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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.
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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.

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Form 3-200-77

Rev. 12/2013

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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.)
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a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

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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.
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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 Accounting 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 Native American Eagle Take permit application is 2 hours and 15 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 3-200-77

Rev. 12/2013

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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 3-200-77

Rev. 12/2013

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