Form 3-200-29 Federal Fish and Wildlife Permit Application Form

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		OMB No. 1018-0093 Expires XX/XX/2017
Return to: Division of Management Authority (DMA) U.S. Fish and Wildlife Service 4401 N. Fairfax Drive, Room 212 Arlington, VA 22203 1-800-358-2104 or 703-358-2104		Type of Activity: Export/Re-Export/Master File of Wildlife Samples and/or Biomedical Samples (CITES) (Circle or highlight your requested activity)

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, Tribe, or institution
4.a. Principal officer Last name			4.b. Principal officer First name				4.c. Principal officer Middle name/ initial		4.d. Suffix
5. Principal officer title 						6. Primary contact name
7.a. Business telephone number		7.b. Alternate telephone number			7.c. Business fax number			7.d. Business e-mail address

C.		Applicant 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 identified on page 2. 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))
2.		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 
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)

E. Export/Re-Export of Wildlife Samples and/or Biomedical Samples (CITES)

For the export/re-export of samples from species listed under the Endangered Species Act or CITES Appendix I species (50 CFR Part 17), use application form 3-200-37 [http://www.fws.gov/international/permits/by-form-number/index.html].

The U.S. FWS may not be able to issue CITES documents for the commercial export of Appendix-I specimens, unless the specimens were obtained from animals produced at a CITES-registered Appendix-I commercial breeding operation. For more information on registering an Appendix-I commercial breeding operation, contact the Division of Management Authority at 800-358-2104 or [email protected].

Use this form if you are collecting in the open ocean on a U.S. registered vessel and transporting the specimens directly to a different country - your shipment would require a U.S. CITES export permit. In addition, if you are exporting Appendix-I specimens, an import permit issued by the country into which the specimens are transported would be required.

E lectronic submission of inventories, photographs, and receipts: Some applications contain extensive inventories and/or a large number of photographs or receipts. You may provide electronic versions of these documents. Such a submission may assist in expediting the processing of your application since it may reduce data entry by the U.S. Fish and Wildlife Service. You may include a disk containing your information or check here  if you would like to be contacted to provide it via email.

Provide the following information. Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If you are applying for multiple specimens, be sure to indicate which specimen you are addressing in each response.

1. What activity are you requesting authorization to carry out?

1a ___SINGLE SHIPMENT for export (Processing Fee = $100)

1b ___SINGLE SHIPMENT for re-export only (Processing Fee = $75)

1c ___ESTABLISHING A MASTER FILE (Processing Fee = $200)

(This application allows you set up a Master File, valid for three years and is renewable, for exports of specimens under CITES. Once the Master File is approved you would need to obtain single-use permits, valid for 6 months, for each export (50 CFR 13.11)) All processing fees are nonrefundable.

1d ___RENEWAL OF AN ESTABLISH MASTER FILE, # _______________ (Processing Fee = $100)

1e ___AMEND AN ESTABLISHED MASTER FILE, # __________________ (Processing Fee = $100)

When establishing a new master file, renewing, or amending a previous master file, please indicate the number of single-use permits do you anticipate using in the next 6 months? ____________________

(Provide $5 for each 6-month permit.) Additional permits may be requested by submitting form 3-200-74 (http://www.fws.gov/international/permits/by-form-number/index.html). All processing fees are nonrefundable.

2.  Provide recipient’s foreign address:

Name:

Address:

City:

State/Providence:

County, Postal Code:

3. For EACH animal from which samples are to be shipped, provide the following (You may use the attached corresponding inventory sheet): Please do NOT include Quarantine, Immunization or Health records unless they document transfer of ownership. (See sample inventory page provided.)

a. Scientific name (genus, species, and, if applicable, subspecies);

b. Common name;

c. Animal's microchip, tag, band, or other identification number or House name;

d. Sex, if known;

e. Birth/hatch date or age class;

f. Source of specimen (Wild or Captive-Born);

g. If this is a re-export, Foreign CITES export permit number and issuance date;

h. Type of sample (e.g., blood samples, cell cultures, tissue samples); and

i. Quantity of samples & how packaged (e.g., 10 1-ml flasks, paraffin blocks, slides).

4. What is the purpose of the export?

____ Commercial ____ Personal ____ Exhibition

____ Scientific  ____ Breeding ____ Other (specify: _____________________________)

5. Where is/are the specimen(s) currently located?

Name:

Address (City, State/Providence, County, Postal Code):

6. For wildlife previously imported into the United States from another country (Re-export), provide:

a. All copies of canceled CITES export or re-export documents issued by the appropriate CITES office in the country from which the wildlife was exported,

b. All copies of cleared wildlife Declaration for Import (Form 3-177),

c. Copies of Inventory sheets that accompanied the original shipment showing original tattoo #’s, and

d. If you did not make the original import, provide copies of the importer's documents outlined above and the invoices or other documents that shows you acquired the wildlife from the original importer or history of transactions (chain of ownership).

7. For samples collected from animals born in the wild in the United States, provide:

a. Specific location of where, when and by whom (name and address) the animal/sample was removed from the wild,

b. A description of the method(s) of collection, including previous results using this methodology (e.g. mortality rate, adverse impacts),

c. The qualifications of the individuals collecting the samples,

d. A copy of any applicable local, Tribal, State, or Federal government authorization approving the activity, and

e. Documentation that the applicant legally acquired the animals/samples.

f. In addition, For wild-born animals currently or previously held in captivity, describe the purpose of removing the animal from the wild, length or approximate length of time the animal was or will be held in captivity, and, if still in captivity, current location (including a history of where the animal has been maintained in captivity).

8. For samples collected from animals born in captivity within the United States:

a. Have the specimens been collected? If not, when will they be collected?

b. If you are the breeder, please provide a dated statement that the animal was bred and born at your facility. This statement must include:

i. name and address of the breeding facility;

ii. birth/hatch date, band/tag number, and sex of each specimen; and

iii. Signature of the attending veterinarian or animal caretaker in charge of the breeding operation.

c. If you are NOT the breeder of the specimen, provide copies of documentation showing that the specimens were legally acquired, such as documentation that demonstrates the history of transactions (e.g., chain of custody) and a dated signed statement from the breeder or breeder's record that includes:

i. Complete name and address of the breeder's facility;

ii. Scientific name; birth/hatch date, sex, and, if applicable, band/tag number or other identifier of each specimen bred;

iii. Statement that the animal was bred and born at the breeder’s facility;

iv. Location (name of holder, city, State, zip code) of parental stock;

v. Whether the parental stock was captive-born or wild-caught; and

vi. Signature of the attending veterinarian, or animal caretaker in charge of the colony

9. For marine mammals samples, provide a copy of your FWS or NOAA Fisheries permit or authorization.

10. All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. If you wish to use a port not listed, please contact the Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).

11. Name and address where you wish permit mailed, if different from page 1 (All permits will be mailed via the U.S. Postal Service, unless you identify an alternative means below):

12. If you wish the permit to be delivered by means other than USPS regular mail, provide an air bill, pre-paid envelope, or billing information. If you do not have a pre-paid envelope or air bill and wish to pay for a courier service with your credit card, please state check the box below. Please DO NOT include credit card number or other information; you will be contacted for this information.

□ If a permit is issued, please send it via a courier service to the address on page 1 or question 11. I understand that you will contact me for my credit card information once the application has been processed.

13. Who should we contact if we have questions about the application? (Include name, phone number, and email):

14. 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 on separate sheet of paper: 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.  

Please do not submit handwritten inventories with your application. You may re-create this spreadsheet as long as it contains all the necessary information.

Export/Re-export of Wildlife Samples (CITES)

INVENTORY PAGE

a. Scientific Name

(genus, species, subspecies)

b. Common Name

c. Original Animal Number

d. Current Animal Number

e. Gender

f. Source Code

(Wild or Captive-Born)*

g. Birth Date(mm/dd/yyyy)

h. CITES

Export Permit No. (If

re-export)

i.

Export Permit Issuance Date (If re-export)

j. Type of Sample

(blood, tissue, DNA)

k. Quantity of samples & how Packaged

(vials, slides, flask)/size and No. of samples

EXAMPLE:

Macaca fascicularis

Crab-eating macaque

RX7272-09

F

W

5/6/1992

VN0101-1998

07/05/98

Liver cells

20 1-ml vials containing 0.5 mls each

Enter column totals for total no. animals, total mls, and total vials/ flasks/ slides, etc:

TOTAL VIALS= TOTAL ML=

If Re-Export use Source Code from the original CITES Export permit.

APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an U.S. Fish and Wildlife Service (FWS) permit applications. 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 relevant 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 applications 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, however, some applications may take longer than 90 days to process (50 CFR 13.11).

• Applications are processed in the order they are received.

SECTION A OR SECTION B:

Section A. Complete if applying as an individual [do not complete this section if applying for Import/Export License (3-200-3)]:

• 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, while helpful in processing, are not required.

• 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, Tribe, 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) and the Office of Law Enforcement (OLE) do not accept doing business as affiliations for individuals (complete Section B)..

Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:

• Enter the complete name of the business, agency, 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. If you are applying on behalf of a client, a document evidencing power of attorney must be included with the application.

• 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, 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) and Office of Law Enforcement (OLE), a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs that use foreign addresses and are not required by DMA.

• Mailing address is the address to which communications from USFWS should be mailed if different from 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. 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, nor will fees be refunded for applications for which processing has begun.

• Documentation of fee exempt status is not required for applications submitted by Federal, Tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Such applications must include 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 recent issued USFWS permit. 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 legally binds the applicant to the statement of certification. You are certifying that you have read and understand the regulations that apply to the permit. You are also certifying that all information 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.

Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION

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. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;

b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;

c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;

d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;

e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;

f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;

g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/ , 50 CFR 23;

h. General Provisions, 50 CFR 10;

i. General Permit Procedures, 50 CFR 13; and

j. 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 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. 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.

b. 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.

c. 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.

d. 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.

e. 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.

f. 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.

g. 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.

h. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.

i. Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.

j. 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 an Import/Export/Re-Export of Trophies of Wildlife Samples and/or Biomedical Samples application is 2 hours 30 minutes. 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 2042-PDM, 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 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].

DO NOT RETURN THIS PAGE WITH THE APPLICATION

Form 3-200-19 Rev. <<Date>> Page 1 of <<#>>