Form 3-200-33 Federal Fish and Wildlife Permit Application Form

Federal Fish and Wildlife Permit Applications and Reports--Management Authority; 50 CFR 12, 13, 14, 15, 16, 17, 18, 21, 23

3-200-33 final

Export of Artificially Propagated Plants - Application (indiv)

OMB: 1018-0093

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Department of the Interior
U.S. Fish and Wildlife Service

Federal Fish and Wildlife Permit Application Form
Type of Activity:
EXPORT OF ARTIFICIALLY PROPAGATED PLANTS (Single and
Multiple Commercial Shipments)
____ New Application
____ Amendment of Master File # _______________
____ Renewal of Master file #
________________

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

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.

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

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

5. Principal officer title

7.a. Business telephone number

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact name

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 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))
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)

Please continue to next page

Form 3-200-33

Rev. 02/2014

Page 1 of 9

This form should be used for the commercial export of cultivated specimens (i.e., species, hybrids, cultivars) of
CITES-listed species that meet the criteria of artificial propagation, as defined by CITES Resolution Conf. 11.11
(Rev. CoP15; http://www.cites.org/eng/res/11/11-11R15.php). All plant taxa must be published in a recognized
scientific journal or reference that has been adopted by CITES.
This application may be used to:
Request a single-use permit for commercial export of artificially propagated plants or plant products
(processing fee = $100) that 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.
Establish a Master File (processing fee = $200 + $5/single use certificates): If approved, a “master file”, or
programmatic export authorization, and an approved plant list will be established that will be valid for up to 3 years.
Once the master file is approved, you must obtain partially completed export certificates, valid for 6 months, to
export specimens of the approved species, hybrids, and cultivars. There is a $5 fee for each partially completed
certificate. Certificates must be obtained prior to making any shipment and must accompany the shipment.
Additional partially completed certificates may be requested by submitting form 3-200-74
(http://www.fws.gov/international/pdf/permit-application-form-3-200-74-single-use-export-permits-under-a-masterfile-or-an-annual-program-file.pdf).
Amend a current Master File (processing fee = $100): This form must be used to amend a current master file. A
master file must be amended when there have been any changes to the information provided for a current master file
(e.g., addition and/or deletions of species/hybrids/cultivars, or changes to the source(s) of plant material). Please
complete only the questions that are relevant to the amendment (e.g., you do not need to provide information
previously submitted when you established the master file if it has not changed).
Renewal a Master File (processing fee = $100): To renew a 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.
I would like to:
___ Request a single-use permit ($100 fee)
___ 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)
This form should NOT be used for a single use export or re-export of artificially propagated or wild-collected
specimens. For such exports, applicants should complete application form 3-200-32
(http://www.fws.gov/international/pdf/permit-application-form-3-200-32-export-re-export-of-plants.pdf).
Some plant species are exemptions under CITES from requiring CITES permits. If you are not sure whether an
exemption applies to your export, please refer to the CITES Appendices
(http://www.cites.org/eng/resources/species.html) or contact the Division of Management Authority at 800-358-2104.
Review this application carefully and provide complete answers to all questions. If a question is not applicable, answer
with “N.A.” If more space is needed, photocopy or download the form at http://www.fws.gov/international/pdf/permitapplication-form-3-200-33-export-of-artificially-propagated-plants.pdf . Please number all questions and answers, as
well as number the pages in the bottom right corner. If you have any questions, please contact the Division of
Management Authority at 800-358-2104.
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
Form 3-200-33

Rev. 02/2014

Page 2 of 10

___check here to be contacted via e-mail to provide an electronic inventory.
This application is divided into SIX (6) parts.
 To export interspecific and intergeneric hybrids of CATTLEYA, CYMBIDIUM, DENDROBIUM (D.
phalaenopsis and D. nobile only), ONCIDIUM (non-native only), PHALAENOPSIS, and/or VANDA, complete
Part II.
 To export specimens other than above-mentioned orchid hybrids, complete Parts III and IV.
 All applicants should complete Parts I and V.
Part I: Facility information (separate sheets of paper may be required to fully answer these questions)
1. Briefly describe your business. Do you propagate all plants or plant material exported by your operation? Do
you propagate some species/subspecies/cultivars/hybrids, while buying other specimens from a single or
multiple propagators? Do you only export specimens obtained directly from a different facility?
2. If you propagate some or all of the specimens to be exported:
a. Please provide a brief description of your facilities and its capacity to propagate specimens.
b. How long have you been in business?
3. If you purchase specimens from other propagators:
a. Do you purchase from a single source or multiple sources?
b. How often do you purchase specimens?
4. If you propagate plants, provide labeled photographs of your growing facilities, parental stock, and specimens
included in your application. If you purchase from another facility, please provide such photographs of that
facility(s).
5. Provide the following documentation:






Provide a copy of your current State nursery license.
Provide your current U.S. Department of Agriculture Protected Plant Permit (formerly known as General
Permit).
For all plant material imported to the United States, submit copies of validated CITES permits and
Phytosanitary Certificates (include all inventory lists if not part of CITES document or certificate) for those
specimens and cross-reference the document to the item number on Table 3 at the top of the document.
For any wild plant material identified in this application, submit copies of authorizations (e.g. collection
permits, land-owner permission, salvage permits) for those specimens and cross-reference the document to
the item number on Table 3 at the top of the document.
For all material obtained from suppliers identified in this application, submit receipts showing the name,
address and telephone number of the person from whom you purchased the plants and the date of purchase
for each specimen or, if not available, signed propagator’s statements (see below) and cross-reference the
document to the item number on Table 3 at the top of the document.

SAMPLE PROPAGATOR’S STATEMENT:
I, __________________________ [state name] declare that the plant material I gave or sold to _____________ on
______________ [date] was not obtained from the wild, but was propagated from parental stock plants maintained
at___________________ [indicate location of parental stock] since _________________ [indicate the year that
the parental stock was established].
[Signature]

Form 3-200-33

Rev. 02/2014

[Date]

Page 3 of 10

PART II. Cattleya, Cymbidium, Dendrobium (D. phalaenopsis and D. nobile only), Oncidium (non-native only), Phalaenopsis, and Vanda Hybrids. Provide the
information requested in Table 1 for interspecific and intergeneric hybrids derived only from Cattleya, Cymbidium, Dendrobium (D. phalaenopsis and D. nobile only),
Oncidium (non-native species only), Phalaenopsis, or Vanda orchids. Both/all parents must come from within this group; please use Table II for hybrids that include any
parental species that are not in this group. Refer to Codes below for sections b-e. For all other specimens, including other orchid hybrids, proceed to Part II.
TABLE 1. CATTLEYA, CYMBIDIUM, DENDROBIUM (D. phalaenopsis and nobile), ONCIDIUM (non-native), PHALAENOPSIS, or VANDA HYBRIDS
Item
No.

a. Hybrid Name
(Include parental genera or grex)

b. Specimen Description
at the time of export
specify code

c. Growing Environment

d. Propagation Method(s)

specify code

e. Name of Propagating Facility

b. Specimen Description: 1=Seedlings; 2=Juveniles; 3=Mature/blooming size; 4=Cuttings/divisions; 5=Roots/rhizomes; 10=Other (specify).
c. Growing Environment: 1 = Greenhouse; 2 = Lathhouse; 3 = Lab; 4 = Field; 5 = Other (specify).
d. Propagation Method to produce the specimens to be exported: 1 = Seeds; 2 = Stem or root/rhizome cuttings/divisions; 3 = In vitro; 4 = Other (specify).

 If you are NOT requesting authorization to export any other specimens, proceed to Part V.

 For all other plants, including orchid hybrids derived from any parental species that are not in the above group, proceed to Part II.

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PART III. Other specimens to be exported (excluding hybrids in Part I). For each species/subspecies/cultivar/hybrid you are requesting to include on your master
file, you will need to provide the following information:
A) Scientific name; B) description of the specimen at the time of export; C) for extracts, powders or specimens in some processed format, the amount (weight or
volume) of specimens to be exported and the estimated number of plants needed to produce the extract/powder/etc.; D) the growing environment used to produce
the specimens; E) the form of propagation used to grow the specimens; and F) the name of the propagating facility. If you obtain specimens of the same
species/subspecies/cultivar/hybrid from multiple sources, you will need to provide all of the above information for each source. The following table is provided
for your convenience. Refer to the Codes below for sections c-f. If you obtain specimens from multiple sources, please complete a separate line for each source.
TABLE 2. SPECIMEN INVENTORY
Item
No.

a. Scientific Name
(Genus, species, sub-species, cultivar)

b. Common Name

If hybrid, list parental species

c. Specimen Description d. For extracts,
e. Growing f. Propagation
at the time of export
powders, or other Environment
Method
specify code
specify code
specify code
Unit
Plants/Unit

g. Name of Propagating
Facility

c. Specimen Description: 1=Seeds; 2=Flasks; 3=Seedlings; 4=Juveniles; 5=Mature/blooming size; 6=Cuttings/divisions; 7=Roots/rhizomes; 8=Extracts; 9=Powders; 10=Other (specify).
d. Unit: Provide the total weight or volume of the item; Plants / Unit: Provide the total number of plants used to produce the total weight or volume.
e. Growing Environment: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify).
f. Propagation Method to produce the specimens to be exported: 1=Seeds; 2=Stem or root/rhizome cuttings/divisions; 3=In vitro; 4=Other (specify).

 Proceed to Part IV.

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PART IV. Maintenance and Origin of Parental Stock (for all specimens in Part III). Table 3 describes the plants used to propagate specimens (i.e., parental
stock) identified in Table 2 (this information does not need to be provided for hybrids included in Table 1). If you do not maintain the parental stock, please obtain
the requested information from the propagator of the specimens. Refer to each specimen using the Item number from Table 2. In question 5, you were asked to
provided certain documentation to support your application – please use the Item number below to cross-reference those documents. Refer to the Codes below for
sections b, c, and h.
TABLE 3. PARENTAL STOCK (for specimens in Part II).
Item
a. No. of
b. Growing c. Origin of d. Supplier NAME if
e. If wild origin, location of
No. parental plants Environment Parental
you do not maintain collection (indicate the country or,
from
specify code
maintained
Stock
parental stock
if U.S., the nearest city, county,
Table 2
specify code
Provide contact
state) Please attach copy of
information in Table 4
CITES export document or
phytosanitary certificate

f. Date(s)
Parental
stock was
Acquired

g. Quantity h. Material i. If you maintain parental stock,
Acquired
Acquired how often do you obtain additional
specify code stock from a supplier or from the
wild? Explain.

b. Growing Environment for parental plants: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify).
c. Origin of Parental Stock: 1=Cultivated; 2=Wild
h. Material Acquired (purchased or collected): 1=Seeds; 2=Flasks; 3=Seedlings; 4=Juveniles; 5=Mature/blooming size; 6=Cuttings/divisions; 7=Roots/rhrizomes; 8=Other (specify).

 Proceed to Part V.

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PART V. Supplier Information (To be completed by all applicants). Complete Table 4 for all suppliers identified in Tables 2 and 3. You and the supplier may
need to be contacted for additional information. If the same supplier was used for more than one item identified in the Tables, you need only supply the requested
information one time.
TABLE 4. SUPPLIER CONTACT DETAILS.
Full Address
Telephone
Fax Number
E-Mail/website (if available)
Name of Supplier
(street address, city, state, country, zip code)
(if available)
Number

 Proceed to Part V.

3-200-33

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Page 7 of 10

PART V. General Information (To be completed by all applicants).

1. Describe the type of shipping containers and the arrangements for LIVE plant care during shipping.

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 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.

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.

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Rev. 02/2011

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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
3-200-33

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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
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 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.

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 a 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 on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for
an Export of Artificially Propagated Plants application is 120 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 nonconfidential 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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PART II. Cattleya, Cymbidium, Dendrobium (D. phalaenopsis and D. nobile only), Oncidium (non-native only), Phalaenopsis, and Vanda Hybrids. Provide the
information requested in Table 1 for interspecific and intergeneric hybrids derived only from Cattleya, Cymbidium, Dendrobium (D. phalaenopsis and D. nobile only),
Oncidium (non-native species only), Phalaenopsis, or Vanda orchids. Both/all parents must come from within this group; please use Table II for hybrids that include
any parental species that are not in this group. Refer to Codes below for sections b-e. For all other specimens, including other orchid hybrids, proceed to Part II.
U

TABLE 1. CATTLEYA, CYMBIDIUM, DENDROBIUM (D. phalaenopsis and nobile), ONCIDIUM (non-native), PHALAENOPSIS, or VANDA HYBRIDS
Item
No.

a. Hybrid Name
(Include parental genera or grex)

b. Specimen Description
at the time of export

c. Growing Environment

d. Propagation Method(s)

specify code

e. Name of Propagating Facility

 If you are NOT requesting authorization to export any other specimens, proceed to Part V.
 For all other plants, including orchid hybrids derived from any parental species that are not in the above group, proceed to Part II.

3-200-33 T1

Rev. 02/2014

Page 1 of 1

a. Scientific Name
(Genus, species, sub-species, cultivar)

b. Common Name

If hybrid, list parental species

c. Specimen
Description
at the time of export

d. For extracts,
e. Growing f. Propagation
powders, or other Environment
Method
specify code
specify code
Unit
Plants/Unit

g. Name of Propagating
Facility

specify code

3-200-33 T2

Rev. 02/2014

Page 1 of 1

PART IV. Maintenance and Origin of Parental Stock (for all specimens in Part III). Table 3 describes the plants used to propagate specimens (i.e., parental
stock) identified in Table 2 (this information does not need to be provided for hybrids included in Table 1). If you do not maintain the parental stock, please obtain
the requested information from the propagator of the specimens. Refer to each specimen using the Item number from Table 2. In question 5, you were asked to
provided certain documentation to support your application – please use the Item number below to cross-reference those documents. Refer to the Codes below for
sections b, c, and h.
TABLE 3. PARENTAL STOCK (for specimens in Part II).
Item
a. No. of
b. Growing c. Origin of d. Supplier NAME if
e. If wild origin, location of
No. parental plants Environment Parental you do not maintain collection (indicate the country or,
from
specify code
if U.S., the nearest city, county,
maintained
Stock
parental stock
Table 2
specify code
Provide contact
state) Please attach copy of
information in Table 4
CITES export document or
phytosanitary certificate

f. Date(s)
Parental
stock was
Acquired

g. Quantity h. Material i. If you maintain parental stock,
Acquired
Acquired how often do you obtain additional
specify code stock from a supplier or from the
wild? Explain.

3-200-33 T3

Rev. 02/2014

Page 1 of 1

PART V. Supplier Information (To be completed by all applicants). Complete Table 4 for all suppliers identified in Tables 2 and 3. You and the supplier may
need to be contacted for additional information. If the same supplier was used for more than one item identified in the Tables, you need only supply the requested
information one time.
TABLE 4. SUPPLIER CONTACT DETAILS.
E-Mail/website (if available)
Full Address
Telephone
Fax Number
Name of Supplier
(street address, city, state, country, zip code)
(if available)
Number

3-200-33 T4

Rev. 02/2014

Page 1 of 1

File Type	application/pdf
Author	hallp
File Modified	2014-02-24
File Created	2014-02-24