Form 3-200-32 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 OF PLANTS and PLANT PRODUCTS (CITES) ___ New Application ___ Amendment or ___Re-issue 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, 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)

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E. EXPORT/RE-EXPORT OF PLANTS (CITES)

Use this application form for a single or multiple exports or re-exports of the following plants or plant products that are regulated under CITES: wild, non-commercial artificially propagated specimens, some commercial artificially propagated plant products, plants for a plant society exhibition, re-export of plants under a carnet, or pre-Convention specimens.

Single Use Permit: A single-use permit is valid for 6 months from the date of issuance. For re-issuance or amendment of a single use permit, the original permit must be returned with this completed application form:

$100 for export - A one-time export of CITES-listed plants or plant products.

$100 for re-export - A one-time export of plants or plant products that were previously imported under a CITES permit.

$75 for pre-Convention specimens – A one-time export of plants or plant products that were obtained prior to their listing under CITES and so are considered “pre-Convention.” The CITES listing date can be found in the CITES Species Database at http://www.cites.org/eng/resources/species.html. NOTE: No CITES import permit is required for an Appendix-I specimen that qualifies as pre-Convention.

$50 for personal/household plants – A one-time export of personally-owned, live potted plants or plant products that are not intended for commercial sale.

Master File: This application form allows you set up a Master File, valid for up to 3 years and is renewable, for exports or re-exports of wild, commercial artificially propagated plant parts or products, or pre-Convention specimens. these plant specimens. Once the Master File is approved, you must also obtain partially completed permits, valid for 6 months, for each export (50 CFR 13.11).

$200 to establish a new Master File

$100 to re-issue or amend an established Master File – Allows you to renew your Master File that has or will soon expire. You must complete this entire application, including providing information on any changes to your facility, operations, species, or suppliers for the plant specimens that you wish to export.

AND

$5 each for required partially completed permits to accompany each shipment under a Master file – Once the Master File is approved, you must also obtain single-use permits; to accompany each export under the Master File (50 CFR 13.11). The Single-use permits will be valid for 6 months and can be requested using this form when establishing or renewing a Master File. For future shipments, additional permits may be requested using FWS Form 3-200-74; http://www.fws.gov/forms/display.cfm?number1=200

This form should NOT be used to request authorization for commercial exports of plants that are artificially propagated in the United States. For such exports, applicants should complete form 3-200-33 (http://www.fws.gov/forms/3-200-33.pdf).

For certain plants, there are exemptions under CITES that do not require CITES permits for some specimens (www.cites.org). If you are not sure whether an exemption applies to your export, contact the Division of Management Authority.

If you are not sure whether a species is regulated under CITES, please refer to the CITES Appendices (www.cites.org/eng/app/appendices.php).

Review this application carefully and provide complete answers to all of the questions. If a question is not applicable, answer with "N/A". If more space is needed, use a separate sheet of paper. On all attachments or separate sheets you submit, indicate the number of the application question that you are addressing. If you are applying for multiple species, be sure to indicate which species you are addressing in each response.

Electronic submission of inventories, photographs, and receipts: Some applications contain long inventories and/or a large number of photographs or receipts. You may provide electronic versions of these documents. Such a submission may assist to expedite the processing of your application since it will eliminate the need for data entry by U.S. Fish and Wildlife Service. You may include a disk containing your information or

___check here to be contacted via e-mail to provide an electronic inventory.

Part I.

1. What activity are you requesting to carry out?

_______ Export or Re-export _______ Personal/household plants

_______ Pre-Convention ______ Other (specify: ___________________________)

2. I would like to:

___ Request a single-use permit for an export or re-export ($100 fee)

___ Request a single-use permit for pre-Convention specimens ($75)

___ Request a single-use permit for personal/household plants ($50)

___ Establish a new Master File ($200 fee)

___ Renew and/or Amend an existing Master File; PRT #___________ ($100 fee)

How many partially completed certificates are you requesting at this time? ___ (fee - $5/certificate)

3. If requesting a single-use permit, provide name and address of recipient (if shipping to yourself, include your foreign address):

Name:

Address:

City:

State/Providence:

County, Postal Code:

4. For EACH plant specimen to be exported, indicate:

a. Scientific name (genus, species, and if applicable, hybrid, variety, cultivar, or subspecies) and common name;

b. General description, quantity and size of the specimen(s) to be exported/re-exported (e.g., 100 whole plants; 2,000 seeds; 100 kg dried root; 20 cu³ sawn logs; 5 guitars)

c. For timber, medicinal, nutritional or other plant products, also provide:

i. Form of product (e.g., plywood, tablet, capsule, fruit bar);

ii. Type of packaging (if applicable);

iii. Unit description, including metric weight or volume of specimen(s) and the quantity of plants or plant parts used to produce the unit weight or volume; and

iv. Product name, if applicable

E.g., 50 bottles of Hoodia, 30 capsules per bottle, each capsule contains 100 mg of H. gordonii; total Hoodia 3,000mg/bottle

d. Country where the plant was acquired; and

e. Source of the specimen (e.g., removed from the wild or artificially propagated).

5. Current location of specimens?

Name:

Address:

City:

State/Providence:

County, Postal Code:

6. Is this shipment a sample collection being exported for temporary exhibition or display purposes and accompanied by a valid ATA carnet?

___ NO ___YES; provide ATA carnet document number ________________.

Part II. In this section, applicants should respond to all questions that are applicable to the requested activity.

7. For plants collected from the wild in the United States, provide the following for each species collected from the wild:

a. Number and size class of specimens collected (e.g., 100 juvenile; 50 mature);

b. Specific location and date of collection for each specimen;

c. Who (name and address) collected the specimens;

d. Copies of documents that indicate that the plants were legally collected (e.g., State permits or licenses, landowner's permission). Be sure to correlate each document to the corresponding plant;

e. Approximate density (e.g., number of plants per acre) and distribution of the species at the collection site(s);

f. Collection methodology (e.g., whether the specimens were removed from an area of few to several patches of plants, percentage of specimens removed; AND

g. Estimate the number of plants collected to how many plants remain at the location.

If you purchased the plants/seeds, provide the invoice or other document that shows the name, address and telephone number of the person from whom you purchased the plants and the date of purchase for each specimen (such documentation should trace back to the original collector).

8. For wild-collected Appendix-I plants, provide a copy of the CITES import permit issued by the Management Authority of the country to which you plan to export the plant(s) or plant specimen(s).

9. For non-commercial artificially propagated plants, provide receipts showing the name, address and telephone number of the person(s) from whom you purchased the plants and the date(s) of purchase for each specimen or, if not available, a signed statement of how, from whom, and when you acquired the plants.

10. For re-export, provide evidence that the specimen(s) was legally imported:

a. Copies of validated CITES export or re-export document issued by the appropriate CITES office in the country from which the plant was imported. The copies must be stamped by Customs and Border Protection or USDA’s Animal and Plant Health Inspection Service (APHIS); AND

b. If you were not the original importer, provide a copy of the invoice or other document that shows how you acquired the plant specimen from the original importer. (Be sure to correlate each document to the corresponding plant.)

10. For pre-Convention plants provide documents, signed statement or other evidence that the plant was obtained prior to its CITES listing date CITES (e.g., bill of sale, USDA or foreign phytosanitary certificate).

11. For Dalbergia nigra (commonly known as Brazilian rosewood or Bahia rosewood), complete one of the following certification statements:

1. Vintage guitar (musical instrument) exporter. If you are requesting a single-use permit to export a vintage guitar(s), provide an inventory of your pre-Convention stock of guitars made using Dalbergia nigra.

If you are requesting to establish a master file for the export of vintage guitars, you will not need to provide an inventory of all guitars that you intend to export. The master file is typically established for up to 3 years, so it would not be possible to identify guitars that are not currently in your possession. Therefore, if we establish a master file, the master file will not establish a limit on the number that can be exported during the life of the master file. However, you will be restricted to exporting only guitars that were manufactured from pre-Convention Dalbergia nigra, harvested prior to June 11, 1992. If this is acceptable, please sign and date the following certification statement:

I certify that all the guitars to be exported under my master file will have been manufactured from pre-Convention Dalbergia nigra wood, harvested prior to June 11, 1992, and will be documented by the guitars' serial numbers or other identification. If requested by the Service, I am willing to report on the number of guitars and their identification numbers that may be exported under my master file when requesting additional partially completed CITES documents under my master file.

Applicant's signature: _______________________________________ Date: ___________

b. Guitar (musical instrument) manufacturer/exporter/lumber exporter. Provide a catalog or inventory of your pre-Convention stock of Dalbergia nigra wood and/or guitars.

I certify that all the guitars/guitar pieces/lumber to be re-exported, and identified in my catalog or inventory, are made from my pre-Convention supply of Dalbergia nigra, harvested prior to June 11, 1992. I further certify that I will not attempt to export more wood or applying for multiple shipments, I request to export up to _______ guitars/pieces of wood in the next 3 years.

Applicant's signature: _______________________________________ Date: ___________

12. For export of plants by a plant society for exhibition provide:

a. A list of the names of the plant society members who would be exporting their plants;

b. The names and dates of the show(s), countries visited, and the approximate dates of export and re-import of the plants; AND

c. A signed and dated statement from the current society president similar to:

“This certifies that the plants, transported to [country where show occurs] through the port of [USDA designated port], under a CITES permit to be issued to [your society’s name], are for exhibition at [name of plant show]. None of the plants being exported will be sold, and all of these plants will be returned to the United States through the port of [USDA designated port] at the conclusion of the show.”

d. Provide documentation or a signed statement of how, from whom, and when you acquired the plants.

13. For commercial shipments, provide a copy of your current State nursery license and your current U. S. Department of Agriculture (USDA) Protected Plant Permit (formerly known as General Permit).

14. For living plants: (a) describe type of shipping container and (b) arrangements for care during shipping:

Part III.

2. 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):

3. 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 2. I understand that you will contact me for my credit card information once the application has been processed.

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

5. 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.  

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. 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), 50 CFR 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 Export/Re-Export of Plants application is 60 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

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