Form 3-1383-C Commercial Activities Special Use Application

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

Commercial Activities
Special Use Permit Application

For Official Use Only:

Refuge Name:
Address:

Approved 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 to determine
applicability of a particular item.
1) Identify the type of Permit you are applying for:

New

Renewal

Modification

Other

Applicant Information
2) Full Name:

3) Title:

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

8) Business Fax #:

9) E-mail:

10) Business Tax ID #:

11a) Within the past 5 years, has the company (entity) , its owners, or any employees who have or will be expected to operate on the refuge,
been convicted, pled nolo contendere, forfeited collateral, or are currently under charges for any violations of any State, Federal, or local law,
or regulations related to fish and wildlife or permit activities?

Yes

No

11b) If you answered “YES” to question #11a, provide the individual’s name, date of charge, charge(s), location of incident, court, and action
taken for each violation.

12) List known assistants/subcontractors/subpermittees: (Only required if the assistants/subcontractors/subpermittees will be operating on the refuge without the
permittee being present.)

Name

Address

Phone #

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Activity Information
13) Activity type: Guiding Hunters
Filming

Photography

Guiding Anglers

Guiding other Outdoor Users

Agriculture

Cabins

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 refuge where the activity is being conducted to determine what information is required.
14) Describe activity by specifically identifying timing, frequency, and how the activity is expected to proceed:

15) Specifically identify location(s):

(GPS location(s) preferred)

16a) Is map of location(s) required?
Yes

No

16b) Is map of location(s) attached?

N/A

17)Estimated number of clients if applicable:

Yes
Per Day

No
Per Season

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

19a) Is Plan of Operation required?
Yes

No

N/A

20a) Is trip schedule required?
Yes

No

N/A

19b) Is Plan of Operation attached?
Yes

No

20b) Is trip schedule attached?
Yes

No
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OMB Control Number 1018-0102
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License/Insurance Coverage/Certification/Permit
Note: Contact the refuge where the activity is going to be conducted to determine if we will require any type of license(s),
insurance(s), certification(s), or permit(s). We may process this Special Use Permit while the applicant obtains them.
21) List any licenses you have for equipment operation (i.e., aviation or commercial boats), pesticide application(s), transporters, or others, if
required:

License Type

Number

Expiration Date

Copy Attached?
Yes/No

22) List any insurance coverage(s) you have such as general liability, aviation, grounding liability, contaminants applicator, medical evacuation,
or others, if required:

Insurance Type

Carrier

Expiration Date

Copy Attached?
Yes/No

23) List any certifications you have such as rat free, hull inspections, CPR/First Aid, or others, if required:

Certificate Type

Expiration Date

Copy Attached? Yes/No

24) List any other Federal, State, or Tribal permits, if required:

Permit Type

Permit Number

Expiration Date

Copy Attached?
Yes/No

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Logistics and Transportation
Note: We do not require all information for each use. See instructions at the end of the notice and contact the refuge to determine
applicability of a particular item.
25a) Does the activity require personnel to stay overnight on the refuge?

Yes

No

N/A

25b) If yes, list names of personnel involved:
List Names

List Names

List Names

List Names

26) Identify and describe all major equipment/gear and materials needed for activity, if required:

27a) Provide detailed information on the logistics for onsite, intersite, and/or ship-to-shore transportation to or on the refuge, if required:

27b) Provide descriptions, license plate and/or identification numbers of vehicles used for onsite transportation, if required:
Vehicle Type

Plate/I.D./Registration #

Vehicle Type

Plate/I.D./Registration #

27c) Provide descriptions, license plate and/or identification numbers of vehicles used for intersite transportation, if required:
Vehicle Type

Plate/I.D./Registration #

Vehicle Type

Plate/I.D./Registration #

27d) Provide descriptions, license plate and/or identification numbers of vehicles used for ship to shore transportation, if required:
Vehicle Type

Plate/I.D./Registration #

Vehicle Type

Plate/I.D./Registration #

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28a) Is fuel cache needed?

Yes

No

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N/A

28b) Specific location(s) of fuel caches: (GPS Coordinates preferred)

29a) Is Safety Plan required?
Yes

No

N/A

29b) Is Safety Plan attached?
Yes

No

Work and Living Accommodations
30) Specifically describe onsite work and/or living accommodations, including spike camps:

31) Specifically describe on or offsite hazardous material storage or other on or offsite material storage space: (Including on and offsite fuel caches.)

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

32)Signature of Applicant: _______________________________________Date of Application:___________________________________

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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.
We also may make routine use disclosures: (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 Commercial Activity
Special Use Permit Application form to average 4 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: The permittee, by operating on the premises, shall be considered 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 11 below. 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
possession, the permittee will still be allowed to reenter as needed to remove his/her property as stated in paragraph 11 below. The acceptance of any
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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 on the premises from
instructions; 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 to determine applicability of this requirement.
2-9) Provide applicant or business full name, organization or business name (if applicable), address, phone, fax, and e-mail.
10) Provide tax identification number of business or individual.
11a-11b) Check box answering the question regarding any violations of State, Federal, or local law, or regulations related to fish and wildlife or permit
activities, if required. If you answered yes to question 11a, supply the detailed information requested in question 11b. Contact the specific refuge
headquarters office where the activity is going to be conducted to determine if we require information on violations of State, Federal, or local law, or
regulations related to fish and wildlife or permit activities.
12) Provide the names and addresses of assistants, subcontractors, or subpermittees. We may require names and address 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.
13) Activity type: identify activity type (such as, guiding hunters, anglers, or other outdoor users, commercial filming, providing other visitor services,
agriculture activities such as haying, grazing, crop planting, logging, beekeeping, and other agricultural products, building or occupying cabins, or other
commercial uses). Describe other commercial uses if not one of the listed categories. Applicants in Alaska should contact the specific refuge headquarters
office where the activity is going to be conducted if you have questions regarding commercial or subsistence activities.
14) Describe Activity: provide detailed information on the activity, including timing, frequency, how the activity is expected to proceed, etc. Permit renewals
may not need activity descriptions if the activity is unchanged from previous permit. Most repetitive activities 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 applicability of this requirement.
15) Location: identify specific location (GPS coordinates preferred) if not a named facility. Most repetitive activities may not require identification of 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 a location is required.
16a-16b) Attach a map of location, if required, and if the activity is not conducted at a named facility. Most repetitive activities may 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 a map is required.
17) Estimate number of clients per day or per season.
18) Activity/site occupancy timeline: 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 do not require an
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activity/site occupancy timeline for each visit. Contact the specific refuge headquarters office where the activity is going to be conducted to determine if
an activity/site occupancy timeline is required.
19a-19b) Attach a Plan of Operation, if required. Most repetitive activities do not require a Plan of Operations for each visit. In addition, permit
renewals may not require a Plan of Operations if the activity is essentially unchanged from the previous permit. Contact the specific refuge
headquarters office listed where the activity is going to be conducted to determine if a Plan of Operations is required.
20a-20b) Attach trip schedule, if required. Most repetitive activities will require trip schedules for each visit. Contact the specific refuge headquarters
office where the activity is going to be conducted to determine if trip schedules are required.
21) Specifically identify types and numbers of licenses, as required. Contact the specific refuge headquarters office where the activity is going to be
conducted to determine the types of licenses required, and to coordinate the simultaneous application for multiple types of licenses. We may
process this Special Use Permit while licenses are being sought, but we may or may not issue the Special Use Permit until appropriate licenses are
obtained.
22) Specifically identify name, type, and carrier of insurance, if required. Contact the specific refuge headquarters office where the activity is going
to be conducted to determine the types of insurance required, and to coordinate obtaining several types of insurance simultaneously with this permit.
We may or may not issue this Special Use Permit while other types of insurance are being obtained.
23) Specifically identify types and numbers of other certifications, if required. Contact the specific refuge headquarters office where the activity is
going to be conducted to determine the types of certifications required, and to coordinate the simultaneous application of multiple certifications. We
may or may not issue this Special Use Permit while other certifications are being obtained.
24) Specifically identify types and numbers of other State, Federal or tribal permits, if required. Contact the specific refuge headquarters office where
the activity is going to be conducted to determine the types of permits required, and to coordinate the simultaneous application of multiple State,
Federal or tribal permits. We may process this Special Use Permit while other State, Federal or tribal permits are being sought, but we may or may not
issue the Special Use Permit until other appropriate State, Federal or tribal permits are obtained.
25a-25b) Provide name(s) of any personnel required to stay overnight, if applicable.
26) Identify all equipment and materials that will be used, if required. Most repetitive activities 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 a list of equipment is required.
27a-27d) Describe and provide vehicle descriptions and license plate or identification numbers of all vehicles, including boats and airplanes, if required.
Motor vehicle descriptions are only required for permittee vehicle, and/or if the vehicle will be operated on the refuge without the permittee being
present. Motor vehicles that are accompanied by the permittee as part of a group (convoy) activity need not be identified if cleared in advance by 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.
28a-28b) Identify specific location(s) of fuel cache(s) (GPS coordinates preferred), if required.
29a-29b) Attach safety plan if required. Contact the specific refuge headquarters office where the activity is going to be conducted to determine if we
require a safety plan.
30) Specifically describe onsite work and/or living accommodations, if required. Include descriptions and locations (GPS coordinates preferred) of spike
camps or other remote work and/or living accommodations that are not part of the base of operations. Contact the specific refuge headquarters office
where the activity is going to be conducted to determine if we require descriptions of on-site work and/or living accommodations.
31) Specifically describe onsite or offsite hazardous material storage, or other material storage space (including on and offsite fuel caches), if required.
Contact the specific refuge headquarters office where the activity is going to be conducted to determine if we require descriptions of hazardous material
storage or other on-site material storage.
32) Print the application (if using the fillable version). Date and sign the application and return to refuge for processing. The refuge official will review
and, if approved, fill out a Special Use Permit, 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.

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