Form 3-200-41a Captive-Bred Wildlife Registration Annual Report

OMB No. 1018-0093 Expires: XX/XX/2017

Captive-Bred Wildlife Registration Annual Report for Calendar Year ________

(due by March 31 of following year)

This information includes activities of all animals at your facility even if they are on loan. Note: Attach a year-end inventory of all species listed on your registration (quantity and sex). 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 __________________________________________ Permit number________________ Address (If location/address has changed since last year, indicate new location and date of change):

Type Of Activity1	Date Of Activity2	Quantity Sex3 (M/F/?)	Scientific Name4	Common Name	Permit No./Name/Complete Address5	Comments
Example: Loan out	4/12/02	1.0	Elephas maximus	Asian elephant	San Diego Wild Animal Park	Id no. XXXXXXXX

MAIL YOUR REPORT TO: CBW 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.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 Captive-Bred Wildlife Registration 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

1 Type of activity: Births (if survived more than 30 days), deaths (include causes and for euthanasia, include reason for euthanasia in comment column) at your facilities, and then list other types of activities (purchase, sale, loan, donation, gift, trade, export).

2 Date of activity is date it occurred, not necessarily the date specimen was born or transferred.

3 Sex (1.0 = Male; 0.1=female; 0.0.1 = Unknown sex).

4 Include only non-native species listed as Endangered or Threatened under the U.S. Endangered Species Act.

5 CBW Registration number and/or name and address of other CBW registrant involved in the transaction.

Form 3-200-41a Rev. 02/2014 Page 2 of 2