Form 3-200-40a ESA Museum Permit Report

	United States Department of the Interior FISH AND WILDLIFE SERVICE
	Washington, D.C. 20240

OMB No. 1018-0093

Expires XX/XX/2017

Dear ESA Museum Permittee:

Enclosed is your new/renewed Endangered and Threatened Species Museum Permit. Please be sure to read all permit conditions and use the ESA Museum permit correctly. Be aware that this permit only authorizes export and re-import of preserved, frozen, dried, or embedded wildlife specimens or herbarium specimens currently accessioned in your museum.

Reporting Requirements. On an annual basis, permittee must provide a report to the Division of Management Authority that may be submitted as a spreadsheet as described in the below table. Copies of all validated Export/Re-import imports must also be submitted along with the annual report. If there is no activity to report, permittee must provide a signed statement confirming that no export/re-import activities occurred during the year being reported. If reports are not received annually, your permit may be subject to revocation.

Outgoing Specimen Report

Date Sent	Description of specimen	Collection Date	Location where obtained	Acquisition no.	Scientific name and common name	Receiving institution, Country

Incoming Specimen Report

Date Received	Description of specimen	Collection Date	Location where obtained	Acquisition no.	Scientific name and common name	Sending institution, Country

If you have additional questions, please contact the Division of Management Authority, 4401 North Fairfax Drive, Room 212, Arlington, Virginia 22203, phone (703) 358-2104 or fax 703 358-2281.

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.shtml.)

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 and Re-import of Museum Specimens 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 3-200-40a Rev. 02/2014 Page 2 of 2