Form 3-1383-G General Special Use Application

OMB Control # 1018-0102
Expiration Date: XX/XX/2017

General Activities

1

Special Use Permit Application
Refuge:

For Official Use Only:

Address:

Permit #:

Attn: (Refuge Official)

Station #:

E-Mail:

Permit Term: from

to

Phone #:
Note: We do not require all information for each use. See instructions at the end of the notice and contact the refuge identified above
to determine applicability of a particular item. Attach additional sheets to the application if the text spaces provided are inadequate.
1) Identify the type of Permit you are applying for:

New

Renewal

Modification

Other

Applicant Information
2) Full Name:

3) Organization:

4) Street Address:
5) City/State/Zip:
6) Phone #:

7) Fax #:

8) E-mail:
9) List known assistants/subcontractors/subpermittees: (Only required if the assistants/subcontractors/subpermittees will be operating on the refuge without the permittee
being present.)

Name/Business

Address

Phone #

Activity Information
10) Activity type:

Event

W ood C utt ing

Cabin/Subsistence Cabin

Group Visit

Educational Activity

Other

Note: Depending on the activity for which you are requesting a permit, we may ask you for the following activity information.
Please contact the specific refuge where the activity is being conducted to determine what information is required.
11) Specifically identify timing, frequency, and how the activity is expected to proceed:

FWS Form 3-1383-G
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OMB Control # 1018-0102
Expiration Date: XX/XX/2017

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12) Activity/site occupancy timeline: (Specifically identify beginning and ending dates, site occupation timeline, hours, clean-up, and other major events.)

13) Expected number of participants, if applicable: Children (1-18 )
14) Grade level of educational group, if applicable:

Adults

Total

Grade

15a) Will staff time/assistance be required for group activities? Yes

No

N/A

15b) If yes, what’s the anticipated time frame?
16a) Plan of Operation required?

Yes

No

N/A

16b) Plan of Operation attached?

Yes

No

17) Specifically identify location(s): (GPS location(s) preferred)

18a) Is map of location(s) required?
Yes

No

18b) Is map of location(s) attached?

N/A

Yes

No

Insurance Coverage/License/Certifications/Permits
Note: Contact the specific refuge headquarters office where the activity is going to be conducted to determine if any type of
insurance, certification(s), or permit(s) will be required. We may process this Special Use Permit while the applicant obtains them.
19) List any insurance coverage you have such as general liability, aviation, grounding liability, contaminants applicator, medical evacuation, or
others, if required:

Insurance Type

Carrier Name

Policy Number

Copy Attached?
Yes or No

20) Identify licenses, certifications, and permits, if required:

License/Certification/Permit
Type

Number (if applicable)

Issued to:

Copy Attached?
Yes or No

FWS Form 3-1383-G
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OMB Control # 1018-0102
Expiration Date: XX/XX/2017

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Logistics and Transportation
Note: Not all information is required for each use. Please contact the specific refuge where the activity is being conducted to
determine what information is required. Attach additional sheets to the application if the text spaces provided are inadequate.
21) Does activity require personnel to stay overnight onsite?

Yes

No

22) List names of personnel involved:

List Names

List Names

List Names

23) Specifically describe all major equipment/gear and materials used, if required:

24a) Provide detailed information on the logistics for onsite, intersite, and/or ship-to-shore transportation to or on the refuge, if required:

24b) Provide descriptions, license plate, or I.D. numbers of vehicles used for onsite, intersite, and/or ship-to-shore transportation, if required:

Type of transportation

(onsite, intersite, or ship-to-shore)

Equipment Type

License/I.D./Registration Numbers

25) Specifically describe onsite work and/or living accommodations:

26) Specifically describe onsite hazardous material storage or other onsite material storage space:

Sign, date, and print this form and return it to the refuge for processing.

30) Signature of Applicant: _______________________________________Date of Application:___________________________________
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OMB Control # 1018-0102
Expiration Date: XX/XX/2017

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Notice
In accordance with the Privacy Act (5 U.S.C. 552a) and the Paperwork Reduction Act (44 U.S.C. 3501), please note the following information:
The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System are authorized by the National Wildlife Refuge System
Administration Act (16 U.S.C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S.C. 460k-460k-4).
The information that you provide is voluntary; however, we require submission of requested information to evaluate the qualifications, determine eligibility,
and document permit applicants under the above Acts. It is our policy not to use your name for any other purpose. We maintain the information in
accordance with the Privacy Act. We will consider all information you provide in reviewing this application. False, fictitious, or fraudulent statements or
representations made in the application may be grounds for revocation of the Special Use Permit and may be punishable by fine or imprisonment (18
U.S.C. 1001). Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit.
No Members of Congress or Resident Commissioner shall participate in any part of this contract or to any benefit that may arise from it, but this provision
shall not pertain to this contract if made with a corporation for its general benefit.
The Permittee agrees to be bound by the equal opportunity “nondiscrimination in employment” clause of Executive Order 11246.
Routine use disclosures may also be made: (a) to the U.S. Department of Justice when related to litigation or anticipated litigation; (b) of information indicating a
violation or potential violation of a statute, rule, order, or license to appropriate Federal, State, local, or foreign agencies responsible for investigating or
prosecuting the violation or for enforcing or implementing the statute, rule, regulations, order, or license; (c) from the record of the individual in response
to an inquiry from a Congressional office made at the request of the individual (42 FR 19083; April 11,1977); and (d) 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 Department of Justice (48 FR 54716; December 6, 1983).
An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB
control number. OMB has approved this information collection and assigned control number 1018-0102. The public reporting burden for this
information collection varies based on the requested specific refuge use. We estimate the relevant public reporting burden for the General Activity Special
Use Permit Application form to average 0.5 hours per response, including time for reviewing instructions, gathering and maintaining data, and
completing and reviewing the form. Mail comments on this form to the Information Collection Clearance Officer, U.S. Fish and Wildlife Service, 4401 N.
Fairfax Drive, MS 2042-PDM, Arlington, Virginia, 22203.
General Conditions and Requirements
1) Responsibility of Permittee: We shall consider the permittee, by operating on the premises, to have accepted these premises with all facilities, fixtures, or
improvements in their existing condition as of the date of this permit. At the end of the period specified or upon earlier termination, the permittee shall
give up the premises in as good order and condition as when received except for reasonable wear, tear, or damage occurring without fault or negligence.
The permittee will fully repay the Service for any and all damage directly or indirectly resulting from negligence or failure on his/her part, and/or the part
of anyone of his/her associates, to use reasonable care.
2) Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all municipal,
county, and State laws applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing national wildlife refuges
and the area described in this permit. The permittee shall comply with all instructions applicable to this permit issued by the refuge official in charge.
The permittee shall take all reasonable precautions to prevent the escape of fires and to suppress fires and shall render all reasonable assistance in
the suppression of refuge fires.
3) Use Limitations: The permittee’s use of the described premises is limited to the purposes herein specified and does not, unless provided for in this
permit, allow him/her to restrict other authorized entry onto his/her area; and allows the U.S. Fish and Wildlife Service to carry on whatever activities
are necessary for: (1) protection and maintenance of the premises and adjacent lands administered by the U.S. Fish and Wildlife Service; and (2) the
management of wildlife and fish using the premises and other U.S. Fish and Wildlife Service lands.
4) Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or interest not
mentioned in this permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the Regional Director
of the U.S. Fish and Wildlife Service and the permit shall not be used for speculative purposes.
5) Compliance: The U.S. Fish and Wildlife Service’s failure to require strict compliance with any of this permit’s terms, conditions, and requirements shall
not constitute a waiver or be considered as a giving up of the U.S. Fish and Wildlife Service’s right to thereafter enforce any of the permit’s terms or
conditions.
6) Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, the U.S. Fish and Wildlife Service
shall retain all money paid under this permit to be used to satisfy as much of the permittee’s obligation as possible.
7) Payments: All payment shall be made on or before the due date to the local representative of the U.S. Fish and Wildlife Service by a postal money
order or check made payable to the U.S. Fish and Wildlife Service.
8) Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the U.S. Fish and Wildlife Service
representative, reserving, however, the rights specified in paragraph 11below. If he/she fails to do so, he/she will pay the U.S. Fish and Wildlife
Service, as liquidated damages, an amount double the rate specified in this permit for the entire time possession is withheld. Upon yielding
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possession, we will still allow the permittee to reenter as needed to remove his/her property as stated in paragraph 11below. The acceptance of any fee
for the liquidated damages or any other act of administration relating to the continued tenancy is not to be considered as an affirmation of the
permittee’s action nor shall it operate as a waiver of the U.S. Fish and Wildlife Service’s right to terminate or cancel the permit for the breach of any
specified condition or requirement.
9) Revocation Policy: The Regional Director of the U.S. Fish and Wildlife Service may revoke this permit without notice for noncompliance with the
terms hereof, or for violation of general and/or specific laws or regulations governing national wildlife refuges, or for nonuse. It is at all times subject to
discretionary revocation by the Director of the Service. Upon such revocation the U.S. Fish and Wildlife Service, by and through any authorized
representative, may take possession of said premises for its own and sole use, and/or may enter and possess the premises as the agent of the
permittee and for his/her account.
10) Damages: The U.S. Fish and Wildlife Service shall not be responsible for: any loss or damage to property including but not limited to crops,
animals, and machinery; injury to the permittee or his/her relatives, or to the officers, agents, employees, or any other(s) who are instructed to be on
the premises; the sufferance from wildlife or employees or representatives of the U.S. Fish and Wildlife Service carrying out their official
responsibilities. The permittee agrees to hold the U.S. Fish and Wildlife Service harmless from any and all claims for damages or losses that may arise
to be incident to the flooding of the premises resulting from any associated government river and harbor, flood control, reclamation, or Tennessee Valley
Authority activity.
11) Removal of Permittee’s Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the U.S. Fish and
Wildlife Service have been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the U.S. Fish and Wildlife
Service official in charge, but not to exceed 60 days, remove all structures, machinery, and/or equipment, etc., from the premises for which he/she is
responsible. Within this period the permittee also must remove any other of his/her property including his/her acknowledged share of products or crops
grown, cut, harvested, stored, or stacked on the premises. Upon failure to remove any of the above items within the aforesaid period, they shall become
the property of the U.S. Fish and Wildlife Service.
Instructions for Completing Application
You may complete the application portion verbally, in person, or electronically and submit to the refuge for review. Note: Please read instructions carefully
as not all information is required for each activity. Contact the specific refuge headquarters office where the activity is going to be conducted to determine
applicability of a particular item. We may add special conditions or permit stipulations to permit prior to approval.
1) Identify if permit application is for new, renewal, or modification of an existing permit. Permit renewals may not need all information requested. Contact
the specific refuge headquarters office where the activity is going to be conducted if you have questions regarding the applicability of a particular item.
2-8) Provide full name, organization (if applicable), address, phone, fax, and e-mail.
9) Provide known names and addresses of assistants, subcontractors or subpermittees. Names and address are only required if the assistants,
subcontractors or subpermittees will be operating on the refuge without the permittee being present. Volunteers, assistants, subcontractors or
subpermittees that are accompanied by the permittee need not be identified.
10) Activity type: check one of the following categories:
• Event;
• Wood cutting;
• Group visit;
• Cabin/Subsistence cabin (subsistence cabins are only allowed on Alaska Refuges);
• Educational activity; or
• Other—any other activity(s) not mentioned above. Please describe “other” activity.
11) Provide detailed information on the activity, including times, frequency, and how the activity is expected to proceed, etc. Permit renewals may not
need activity description if the activity is unchanged from previous permit. Most repetitive activities, such as group visits, do not require an activity
description for each visit. Contact the specific refuge headquarters office where the activity is going to be conducted to determine if we require an
activity description.
12) Identify beginning and ending dates, site occupation timeline, hours, clean-up, and other major events. Permit renewals may not need an activity/site
occupancy timeline, if the activity is unchanged from previous permit. Most repetitive activities, such as group visits, do not require an activity/site
occupancy timeline for each visit. Contact the specific refuge headquarters office where the activity is going to be conducted to determine if we require
an activity/site occupancy timeline.
13-14) Provide an estimate of the number of adults, and children and grade level of group, if applicable.
15a-15b) Identify if group activities will require onsite refuge staff and the anticipated time frame, if applicable.
16a-16b) Identify and attach a Plan of Operation, if required. Most repetitive activities, such as group visits, do not require a Plan of Operation for each visit.
In addition, permit renewals may not require a Plan of Operation if the activity is essentially unchanged from the previous permit. Contact the specific
refuge headquarters office where the activity is going to be conducted to determine if a Plan of Operation is required.
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17) Identify specific location (GPS coordinates preferred), if not a named facility. Most repetitive activities, such as group visits, do not require a
location. In addition, permit renewals may not require a location if the activity is essentially unchanged from the previous permit. Contact the specific
refuge headquarters office where the activity is going to be conducted to determine if we require a location.
18a-18b) Attach a map of location, if required, and if the activity is not conducted at a named facility. Most repetitive activities, such as group visits,
do not require a map. In addition, permit renewals may not require a map if the activity is essentially unchanged from the previous permit. Contact the
specific refuge headquarters office where the activity is going to be conducted to determine if we require a map.
19) Provide name, type, and carrier of insurance, if required. Contact the specific refuge headquarters office where the activity is going to be
conducted to determine if we require insurance and type of insurance.
20) Specifically identify type(s) and number(s) of other licenses, certifications or permits, if required. Contact the specific refuge headquarters office
where the activity is going to be conducted to determine the type(s) of licenses, certifications or permits required, and to coordinate the simultaneous
application of several types of licenses, certifications or permits. We may or may not issue this Special Use Permit (SUP) while the permittee obtains
other licenses, certifications, and/or permits.
21-22) Provide name(s) of any personnel required to stay overnight, if applicable.
23) Identify all equipment and materials that will be used, if required. Most repetitive events, such as group visits, do not require a list of equipment. In
addition, permit renewals may not require a list of equipment if the event is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if we require a list of equipment.
24a-24b) Provide vehicle descriptions and license plate or identification numbers of all vehicles, including boats and airplanes, if required. We only require
motor vehicle descriptions for permittee vehicle, and/or if the vehicle will be operated on the refuge without the permittee being present. Motor vehicles
accompanied by the permittee as part of a group (convoy) activity need not be identified if cleared in advance by the refuge supervisor. Specifically
describe ship-to-shore, intersite (between islands, camps, or other sites) and onsite transportation mechanisms, and license plate or identification
numbers, if required.
25) Specifically describe onsite work and/or living accommodations, if applicable.
26) Specifically describe onsite hazardous material storage, or other onsite material storage space (including on and offsite fuel caches).
27) Sign, date, and print the application. Click on the Print button to print the application (if using the fillable version). The refuge official will review and,
if approved, fill out the remaining information, sign, and return a copy to you for signature and acceptance.

This application form is not valid as a permit
but may be used as a reference document attached to the official permit.
Only official refuge personnel may assign a valid permit number and permit term
to this application form after the permit has been approved.

FWS Form 3-1383-G
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