Form 3-200-39 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: CERTIFICATE OF SCIENTIFIC EXCHANGE - COSE (CITES)  ­­_____ New Application  Requesting Re-issuance/Amendment of Permit# ____________
Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.

A.	Complete if applying as an individual
1.a. Last name			1.b. First name		1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)		3. Social Security No.	4. Occupation		5. Affiliation/ Doing business as (see instructions)
6.a. Telephone number		6.b. Alternate telephone number		6.c. Fax number	6.d. E-mail address

B.	Complete if applying on behalf of a business, corporation, public agency. Tribe or institution
1.a. Name of business, agency, Tribe, or institution				1.b. Doing business as (dba) 
2. Tax identification no.			3. Description of business, agency, 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 of $100, nonrefundable processing fee. 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. CERTIFICATE OF SCIENTIFIC EXCHANGE (COSE) (CITES)

Note 1. A Certificate of Scientific Exchange (COSE) only authorizes the non-commercial loan, donation or exchange between scientists or scientific institutions registered by a Management Authority of their country, of preserved, dried or embedded specimens, herbarium specimens and live plant material which carries a label issued or approved by a Management Authority. The CITES web site has a list of all registered institutions at http://www.cites.org/common/reg/e_si.html. If specimens are protected by other U.S. laws and/or treaties, such as the Endangered Species Act, Marine Mammal Protection Act, Migratory Bird Treaty Act, or Bald and Golden Eagle Protection Act, you are required to obtain additional authorizations prior to any export or re-import of those specimens.

Note 2. A COSE cannot be used with specimens collected by field researchers unless such specimens are first accessioned into the collection of a registered facility in the state of origin. For the import or export of specimens that are not part of your museum collection, have not yet been collected, or accessioned into your collect, you will probably need to submit form 3-200-37. If you have questions, please contact the Division of Management Authority at the telephone number on page one.

For re-issuance, include the original certificate and the annual report (see Form 3-200-39a). The report is a summary of all imports and exports conducted under the COSE for the past year; including information that appears on the COSE container label such as scientific name and common name, date sent, description of specimen, acquisition number, receiving institution, country, and COSE number.

ENTER an "X" in the box that applies.

1. Is the institution or collection an accredited scientific institution/collection? If yes, indicate the name of the accrediting organization. If additional relevant information about the institution is available on the web, please provide the URL address. If no, provide additional information related to the institution’s standards for record-keeping for and accessibility to the collection.

_____ YES _____ NO

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Are the collections and associated data permanently housed and professionally curated? If yes, how long have the collections been permanently housed and professionally curated. Provide the physical address for the collection and the name and contact information for the curator.

_____ YES _____ NO

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Are all accessions properly recorded in a permanent catalogue?

_____ YES _____ NO

4. As appropriate, ENTER approximate number of accessioned specimens:

_______ Mammals _______ Birds

_______ Insects/Arachnids _______ Other Invertebrates

_______ Reptiles/Amphibians _______ Vascular Plants

_______ Fish _______ Other (specify:__________________________)

5. Do you maintain any specimens protected under the Marine Mammal Protection Act?

_____ YES _____ NO

a. If "yes," do you intend to import or export these specimens? ___________________________

b. If “yes”, provide a copy of your MMPA authorization for this activity.

6. Do you maintain or intend to obtain any specimens protected under the Endangered Species Act?

_____ YES _____ NO

a. If "yes", do you intend to import or export these specimens? ___________________________

b. If “yes”, provide a copy of your ESA authorization for this activity.

7. Do you maintain of intend to obtain any specimens protected under the Migratory Bird Treaty Act?

_____ YES _____ NO

a. If "yes", do you intend to import or export these specimens? ___________________________

b. If “yes”, provide a copy of your MBTA authorization for this activity.

8. Do you maintain any specimens protected under the Bald and Golden Eagle Protection Act?

_____ YES _____ NO

a. If "yes", do you intend to import or export these specimens? ___________________________

b. If “yes”, provide a copy of your MBTA authorization for this activity.

9. Are specimens accessible to qualified users from outside your institution?

_____ YES _____ NO

ENTER approximate number: In the United States Outside the United States

Loans last year: ________________ ____________________

Exchanges last year: ________________ ____________________

Donations last year: ________________ ____________________

10. Are permanent records maintained on specimens that are loaned or transferred?

_____ YES _____ NO

11. Are specimens acquired primarily for the purpose of research, the results of which are to be reported in scientific publications?

_____ YES _____ NO

12. Are specimens prepared and the collections arranged in a manner that ensures their availability?

_____ YES _____ NO

13. Are data on specimen labels, permanent catalogues, and other records as accurate as possible?

_____ YES _____ NO

14. To the best of your knowledge, were the specimens in your collection acquired legally under the relevant laws of the country where they were obtained and the United States (e.g., import permits, collection permits, take permits, land owner permission)?

_____ YES _____ NO

15. Are all specimens of species included in Appendix I of CITES permanently and centrally housed under direct control of the scientific institution as indicated in CITES Resolution Conference 11.15 (www.cites.org)?

_____ YES _____ NO

16. Are Appendix I specimens intended for exchange managed in such a manner to preclude their use solely as decorations or trophies, or for other purposes incompatible with the principles of CITES?

_____ YES _____ NO

17. 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).

18. 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):

19. 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 certificate is issued, please send it via a courier service to the address on page 1 or question 19. I understand that you will contact me for my credit card information once the application has been processed.

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

21. 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.  

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 blocks/lines/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 application or if applicable on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 30 days for your application to be processed. Some applications may take longer than 90 days to process. (50 CFR 13.11)

• Applications are processed in the order they are received.

Additional forms and instructions are available fromhttp://www.fws.gov/forms/display.cfm?number1=200

COMPLETE EITHER SECTION A OR SECTION B:

Section A. Complete if applying as an individual:

• Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the applicant. Fax and e-mail are not required if not available.

• If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be included with the application.

• Affiliation/ Doing business as (dba): business, agency, organizational, 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) will not accept doing business as affiliations for individuals.

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

• Enter the complete name of the business, agency or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the applicant is engaged in. Provide contact phone number(s) of the business.

• Principal Officer is the person in charge of the listed business, corporation, public agency, Tribe, or institution. The principal officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at the business, corporation, public agency, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted to the Division of Management Authority (DMA) a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs which use foreign addresses and are not required by DMA.

• Mailing address is address where communications from USFWS should be mailed if different than applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is required at the time of application; unless exempted under 50 CFR13.11(d)(3). The application processing fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit. Fees will not be refunded for applications that are approved, abandoned, or denied. We may return fees for withdrawn applications prior to any significant processing occurring.

• Documentation of fee exempt status is not required for Federal, Tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Those applicants acting on behalf of such agencies must submit a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most current FWS or CITES permit or the number of the most recent permit if none are currently valid. If applying for re-issuance of a CITES permit, the original permit must be returned with this application.

Section D.3 CERTIFICATION:

• The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation must be included in the application) must sign and date the application in blue ink. This signature binds the applicant to the statement of certification. This means that you certify that you have read and understand the regulations that apply to the permit. You also certify that everything included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

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 a Certificate of Scientific Exchange 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

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