3-200-72 Federal Fish and Wildlife Permit Application Form

OMB Control No. 1018-0022
Expires <>

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:

Eagle Nest 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.f. Country

1.e. County/Province

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.

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 $500.00 (standard) or $1,000 (programmatic) nonrefundable
processing fee if you are applying for a new permit or $150.00 (standard) or $500 (programmatic) nonrefundable processing fee if you are requesting a substantive
amendment of your existing valid permit.. 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

3.

2.d. Zip code/Postal code:

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)

Please continue to next page

Form 3-200-72

Rev. 12/2013

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SECTION E. Eagle Nest Take
(Bald and Golden Eagle Protection Act, 50 CFR 22.27)

Note: A Federal eagle nest take permit authorizes the removal of bald eagle or golden eagle nests for human safety, the safety of
eagles, or the public’s welfare. Permits are available to individuals, agencies, businesses, and other organizations. This permit
does not authorize possession of any eagle or eagle parts including nests or the lethal take of any eagle eggs. Please read “What
You Should Know About a Federal Permit for Eagle Nest Removal” and the regulations at 50 CFR 21.27 before you sign and
submit your application.
Please provide the information requested below. You may use the space provided as well as a separate sheet of paper with your responses
numbered according to the application questions. You should be as thorough and specific as possible in your responses. Incomplete
applications will be returned, delayed or abandoned. Processing time depends on the complexity of the request and completeness
of the application.
Although you may submit supplemental documents that contain the required information, you must respond to each application
requirement below specifically in a single attachment that includes all and only the information required by the application.
Enumerate each response in accordance with the question numbers below Please do not send pages that are over 8.5” x 11” or
DVDs.
1.

2.

Provide the name and contact information for any U.S. Fish and Wildlife Service employee(s) who has provided technical
assistance or worked with you on this project.
Describe the situation that necessitates removal of the eagle nest(s), including:
(a)

The number of nests proposed to be taken;

(b)
(c)

Whether the nest is a bald eagle or golden eagle nest;
Whether the nest is active or inactive and how this was determined. (An active nest may only be taken to alleviate an
immediate safety emergency. A “safety emergency” means “a situation that necessitates immediate action to alleviate a
threat of bodily harm to humans or eagles.” An inactive nest is one that is not currently used by eagles as determined by
the absence of any adult, egg, or dependent young at the nest during the 10 days before the nest is taken.)
When you propose to take the nest.

(d)
3.

Is the nest take necessary to alleviate a safety emergency?

 Yes

 No

(a) If “Yes”, provide the following:
(1) Describe the safety emergency and why the situation was not foreseeable
(2) Explain why removal of the nest is necessary to alleviate it
(b) If “No”, provide the following:
(1) Explain why removal of the nest(s) is necessary)
(2) A calculation of the bald eagle or golden eagle area nesting population, including an appropriately scaled map or
plat showing the location of each eagle nest used to calculate the area nesting population unless the Service has sufficient
data to independently calculate the area nesting population.
(3) A description of the avoidance, minimization, and mitigation measures you have used to reduce the need to take the
nest, to offset the take, or in some situations (see 50 CFR 22.27(b)(7)) to provide a net benefit to eagles.
4.

If the nest is built on a human-engineered structure, provide the following:
(a) a detailed description of the structure and how the nest renders the structure inoperable for its intended use.
(b) maps, digital photographs and detailed description of the situation.

5.

Provide a description of the property, including maps and digital photographs that show the location of the nest in relation to
buildings, infrastructure, and human activities.

6.

Provide the location of the property, including city, county and latitude and longitude geographic coordinates.

7.

If the nest will be removed, how will you prevent future nesting on the same structure/in the area?

8.

Provide the length of time for which the permit is requested, including beginning and ending dates.

Form 3-200-72

Rev. 12/2013

Page 2 of 5

9.

When an active nest must be removed under this permit, any take of nestlings or eggs must be conducted by a Service-approved,
qualified, and permitted agent, and all nestlings and viable eggs must be immediately transported to foster/recipient nests or a
rehabilitation facility permitted to care for eagles, as directed by the Service. Provide a statement outlining how the eagle’s nest
will be removed, indicating the intended disposition of the nest, and if active, a description of how the nestlings or eggs will be
removed, including the recipient nest(s) or federally permitted rehabilitation facility that is authorized for the possession of live
eagle(s) or eggs, and/or eagle nest(s).

10.

If the nest will be removed or relocated (rather than destroyed in the course of an activity), provide the name, address, phone
number, and e-mail address of the qualified party conducting the removal and/or relocation.

11.

You must retain records relating to the activities conducted under your permit for at least 5 years from the date of expiration of
the permit. Please provide the address where these records will be kept.

12.

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

13.

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 3-200-72

Rev. 12/2013

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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 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 3-200-72

Rev. 12/2013

Page 4 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 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 for information collection varies depending on the activity for which a permit is requested. The relevant burden for an
Eagle Nest Take (standard) permit application is 16 hours and 6 hours for a (standard) permit amendment. For an Eagle Nest Take (programmatic)
permit application, the relevant burden is 40 hours and 20 hours for a programmatic permit amendment. 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 3-200-72

Rev. 12/2013

Page 5 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]

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 3-200-72

Rev. 12/2013

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