Form 3-200-30a Annual Report for Exhibition Permittees

OMB No. 1018-0093

Expires XX/XX/2017

Annual Report for Exhibition Permittees Calendar Year ________

(due by March 31 of following year)

This information includes activities of all animals or specimens that have been permitted by the U.S. Fish and Wildlife Service for the past five years, whether or not they are in the United States or abroad. This form may be copied. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form. Additional information may be attached to the report.

Permittee __________________________________________ Address (If location/address has changed since last year, indicate new location and date of change):

CITES and/or ESA Permit #	Species	Identifying information (house name, microchip number)	Date animal last left U.S.	Most recent country to which animal traveled	Date returned (if applicable)	If animal has not returned, expected date of return	Employee with whom animal is traveling	Circus/Exhibition with which the animal is traveling	Attach photos of conservation education material presented to audience

MAIL YOUR REPORT TO: Exhibition Annual Report, USFWS, Division of Management Authority, 4401 N. Fairfax Drive, Rm. 212, Arlington, Virginia 22203

FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act – Notice

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.), 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. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form.

3. The relevant burden for the report conditioned by an issued Export/Re-Export/Re-import of Circuses and Traveling Animal Exhibitions permit is 30 minutes. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the report. You may direct comments regarding the burden estimate 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.

DO NOT RETURN THIS PAGE WITH THE APPLICATION

Form 3-200-30a Rev. 02/2014 Page 2 of 2