Form 3-200-87 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: Transfer/Transport of Captive-held Marine Mammals (MMPA)

Complete Sections A or B, 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 $0 (no fee required). 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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5. Notification for and Transfer/Transport of Captive-held Marine Mammals under the Marine Mammal Protection Act (MMPA)

Note 1: This application is for the transfer of live captive-held marine mammals under the jurisdiction of the Fish & Wildlife Service (sea otters, polar bears, and walrus). The current holder of the live animal should use this application to EITHER: (1) provide NOTIFICATION of transfer/transport and/or sale/purchase of an animal that qualifies as public display under the MMPA; OR (2) request a LETTER OF AUTHORIZATION (LOA) to transfer/transport an animal that was originally stranded and needs long-term care at another facility.

Note 2: This application can be used to request a LETTER OF AUTHORIZATION for the transfer of dead marine mammal specimens to be used for public display or scientific research. The requestor should complete the application and provide a letter of agreement from the current holder of the animal or dead specimen.

Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use separate sheets of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If applying for more than one specimen, be sure to answer all relevant questions for each specimen.

1. Type of activity requested (check appropriate box):

1. ___ Notification (must be provided at least 15 days prior to any proposed transfer/transport, sale, or purchase)

1. Provide a copy of the original permit and/or the most recent DMA transfer/transport confirmation letter (if not available, provide information about the animal’s lineage); and

2. Indicate the purpose of the proposed activity (public display, scientific research, or enhancement).

2. ___ Letter of Authorization (For non-emergency placements of live animals or transfer of dead specimens, please allow a minimum of 30 days to process your request)

2. Provide the estimated date of the proposed activity.

3. Provide the following for the subject animal/specimen:

1. Live animal or dead specimen?

2. Scientific name (genus, species, and, if applicable, subspecies) and common name.

3. Name and sex of the marine mammal.

4. Other identification (e.g., I.D. #, tattoo #, microchip # (provide manufacturer and location of microchip), distinguishing marks/features).

5. Estimated or actual birth date of the marine mammal and place of birth or location of take from the wild.

4. Provide the name and address of the receiving facility (for live animals) or the sending facility (for dead specimens) and the primary contact’s name, title, and information (phone, fax, and e-mail).

Name of [ ___Receiving or ___Sending (check one)] facility:

Address:

Primary Contact and Title:

Phone/Fax:

E-mail address:

5. If the animal/specimen will be under public display, provide a letter from the receiving facility that contains the following information:

1. The marine mammal will be used in a conservation and/or education program based on professionally recognized standards of the public display community. Please identify which standards are followed: AZA, Alliance, or other professionally recognized standards;

2. The exhibitor’s USDA license/registration number issued under the Animal Welfare Act and expiration date; and

3. The facility is open to the public on a regularly scheduled basis and access to the facility is not limited or restricted other than by charging an admission fee.

6. If the animal/specimen will be used for scientific research provide either the FWS scientific research permit number or the following information. [For research that will be done in an invasive manner on live animals please submit form 3-200-43]:

1. Explain how the research meets the MMPA definition of “bona fide research,” i.e., scientific research on marine mammals, the results: (i) are likely to be accepted for publication in a referred scientific journal; (ii) are likely to contribute to the basic knowledge of marine mammal biology or ecology; or (iii) are likely to identify, evaluate, or resolve conservation problems.

2. Attach a copy of the formal research proposal or a detailed description of the proposed project, objectives, methods, anticipated results, and disposition of the animal.

3. Provide the expected research schedule (clearly specify the proposed start and end date(s) of your research and overall duration of the project).

4. Provide a statement with the names and qualifications of the researcher(s) (curricula vitae may be submitted).

7. If the animal will be used for the purpose of enhancing the survival or recovery of the species, provide the FWS permit number.

8. For the transfer of LIVE animals where the species is new to the receiving facility, provide:

1. A complete description, including photographs and/or diagrams (no blueprints), of the area and facilities where the animal will be held (including the dimensions of pools and haul-out areas);

2. A statement (or attach curricula vitae) about the animal caretakers, which describes their specific experience in the care, handling, and maintenance of this species; and

3. A description of all deaths of FWS marine mammal species at the facility within the past five years and the steps taken to prevent or decrease similar mortalities.

FOR LETTERS OF AUTHORIZATION FOR TRANSFER OF LIVE ANIMALS ANSWER QUESTIONS 9 THROUGH 11.

9. Provide the number of animals of this marine mammal (include age and sex) presently maintained at the receiving facility, and whether there is space for additional animals without exceeding USDA/APHIS standards.

10. For placement of a stranded animal at the receiving facility:

1. If this is the initial placement for long-term care and maintenance, provide:

1. A description of the circumstances regarding the animal’s removal from the wild and the permit or authorization number; and

2. The information as specified in your permit/authorization if you are requesting that the FWS determine the animal to be non-releasable.

2. If this is a subsequent placement, provide a copy of the LOA that placed the animal at your current holding facility.

11. Provide a draft transport plan that documents compliance with USDA regulations for transport and care of live marine mammals (7 U.S.C. 2131-2159; 9 CFR 3, Part E) and includes the following information. A description of:

1. the means and duration of the transportation used to move the animal;

2. the type, size, and construction of all shipping containers used to transport the animal;

3. the arrangements for watering or otherwise caring for the animal during transport;

4. the transport contingency plan; and

5. the qualifications of each person and their responsibilities while accompanying the animal that demonstrates their ability to address the specimen’s needs during transport.

FOR ALL APPLICANTS

12. 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):

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

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

15. 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 the standard permit form 3-200 that must be completed as an application for a U.S. Fish and Wildlife Service or CITES permit. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates will be 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 60 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 from http://permits.fws.gov/ .

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, Tribe, 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, 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 a 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 Transfer/Transport of Live Captive-held Marine Mammals 1 hour. 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 <<#>>