Gulf of Mexico On Line IFQ account application

OMB Control No. 0648-0551 Exp. Date: 11/30/2014

U.S. DEPT OF COMMERCE, NOAA NMFS IFQ Program, F/SER29 263 13th Avenue South St. Petersburg, FL 33701-5511 Toll Free 866-425-7627 (8 a.m. - 4:30 p.m. ET) 727-824-5305 (8 a.m. - 4:30 p.m. ET) http://ifq.sero.nmfs.noaa.gov

NOAA FISHERIES SERVICE FEDERAL APPLICATION FOR GULF OF MEXICO INDIVIDUAL FISHING QUOTA (IFQ) ONLINE ACCOUNT

FOR OFFICE USE ONLY

Reviewer's Initials and Date ___________________________

Sanction Case Number if Sanctioned and date held __________________________________________________

Date Sanction Released and Initials _____________________

Application ID

APPLICATION INSTRUCTIONS

1. Current IFQ participants need to complete this application to certify they are or are NOT a United States citizen or a permanent resident alien.

2. As of January 1, 2012, all United States citizens and permanent resident aliens are eligible for participation in the Gulf red snapper IFQ program. This application is to establish an IFQ account for new participants and update account information for existing participants. However, a valid commercial permit for Gulf reef fish, a Gulf red snapper IFQ vessel account, and Gulf red snapper IFQ allocation are required to possess (at and after the time of the advance notice of landing), land or sell Gulf red snapper subject to this IFQ program.

3. Follow the instructions at the top of each section. Make sure all the information is correct then sign and date the application below. The IFQ applicant signing the application must be an account holder listed in section 1 and a United States citizen or permanent resident alien.

4. Mail your completed application to: U.S. Department of Commerce, NOAA, National Marine Fisheries Service F/SER29, 263 13th Avenue South, St. Petersburg, FL 33701-5505.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other suggestions for reducing this burden to PRA Officer, National Marine Fisheries Service, F/SER2, 263 13th Avenue South, St. Petersburg, FL 33701-5505.

The National Marine Fisheries Service requires this information for the conservation and management of marine fishery resources. The data reported will be used to develop, implement, and monitor fishery management activities for a variety of uses. Responses to this collection are required to obtain or retain an IFQ online account under the Magnuson-Stevens Act. Non-confidential information will be released via a NOAA Fisheries Service website. Non-confidential information means: name, address, city, state, zip code, etc. All other data submitted will be handled as confidential material in accordance with NOAA Administrative Order 216-100, Protection of Confidential Fishery Statistics. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

SIGNATURE OF APPLICATION

The undersigned certifies under penalty of perjury that the foregoing information is true and correct (28 USC 1746; 18 USC 1621; 18 USC 1001, 16 USC 1857). Knowingly supplying false information for the purpose of obtaining an IFQ Online Account is a violation of Federal law punishable by a fine and/or imprisonment. Please note: The individual signing below MUST be either the IFQ account holder OR must be one of the officers or shareholders that is a United States citizen or permanent resident alien listed in section 2 of this application.

Applicant Signature ________________________________ Position in Company (if applicable) ___________________________

Print Name_______________________________________ Date ____________________ UserID ____________

(if applicable)

1. IFQ ONLINE ACCOUNT HOLDER INFORMATION

1) Check the appropriate box below if the applicant is a new or existing IFQ online account holder. Provide the USER ID for an existing account holder.

2) Complete this page for all IFQ online account holders. If the account holder is a business, enter the Federal ID number and date the business filed with the state. If the account holder is an individual, enter their Social Security Number and date of birth.

3) Check the appropriate box below to certify that the applicant IS or IS NOT a United States citizen or permanent resident alien.

4) If the IFQ account is held by a business, please also complete Section 2 on page 4.

Check the appropriate box below:

NEW IFQ online account holder

EXISTING IFQ online account holder and provide the IFQ Online account holder’s UserID: ___________________

E-mail address: _________________________________________________________________________________________________

IFQ ONLINE ACCOUNT HOLDER INFORMATION

Check one: Individual/Sole Proprietorship Joint Ownership Partnership Corporation Other ______________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name or Name of Business First Name Middle Name Suffix

If you are operating under a different name,
what is your Doing Business As (DBA) name?

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

Tax ID number (FED ID or SSN) Date of Birth or Date Business Filed (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

ADDITIONAL IFQ ONLINE ACCOUNT HOLDER INFORMATION

Check one: Individual/Sole Proprietorship Joint Ownership Partnership Corporation Other ______________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name or Name of Business First Name Middle Name Suffix

If you are operating under a different name,
what is your Doing Business As (DBA) name?

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

Tax ID number (FED ID or SSN) Date of Birth or Date Business Filed (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

ADDITIONAL IFQ ONLINE ACCOUNT HOLDER INFORMATION

1) Only complete this page for all additional IFQ online account holders. If the account holder is a business, enter the Federal ID number and date the business filed with the state. If the account holder is an individual, enter their Social Security Number and date of birth.

2) Check the appropriate box below to certify that the applicant IS or IS NOT a United States citizen or permanent resident alien.

IFQ online account holder’s UserID (if applicable):

ADDITIONAL IFQ ONLINE ACCOUNT HOLDER INFORMATION

Check one: Individual/Sole Proprietorship Joint Ownership Partnership Corporation Other ______________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name or Name of Business First Name Middle Name Suffix

If you are operating under a different name,
what is your Doing Business As (DBA) name?

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

Tax ID number (FED ID or SSN) Date of Birth or Date Business Filed (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

ADDITIONAL IFQ ONLINE ACCOUNT HOLDER INFORMATION

Check one: Individual/Sole Proprietorship Joint Ownership Partnership Corporation Other ______________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name or Name of Business First Name Middle Name Suffix

If you are operating under a different name,
what is your Doing Business As (DBA) name?

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

Tax ID number (FED ID or SSN) Date of Birth or Date Business Filed (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

2. OFFICER/SHAREHOLDER INFORMATION FOR

CORPORATION/BUSINESS/LLC THAT HOLD THE IFQ ONLINE ACCOUNT

1) If this IFQ online account is held by a business, then complete this section for EACH officer or partner associated with the business.
Provide the information for all officers or partners that are shown on your most recent annual report. If your business is structured as a corporation, identify all shareholders in the corporation that own at least 1% or more of the shares, as well as the percentage of all shares in the corporation held by each shareholder. Individuals holding less than 1% of the shares (minor shareholders) should not be individually listed. Total shareholders must equal 100%. For all provide position held in business, name, address, social security number, date of birth, and telephone number.

2) Check the appropriate box below to certify that the applicant is or is NOT a United States citizen or permanent resident alien.

Business name _____________________________________ Federal Tax ID number ____________________

Officer or Shareholder Information

Check all that apply: President/CEO Vice President Secretary Treasurer Director/Manager Other __________________ Shareholder Percent (%) of corporation held: _______________________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name First Name Middle Name Suffix

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

SSN Date of Birth (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

Additional Officer or Shareholder Information

Check all that apply: President/CEO Vice President Secretary Treasurer Director/Manager Other ________________ Shareholder Percent (%) of corporation held: _______________________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name First Name Middle Name Suffix

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

SSN Date of Birth (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

_________ MINOR SHAREHOLDERS - Check here if one or more of your shareholders each individually hold shares that total less than 1% of the total shares of the corporation/business/LLC. For example, there might be three shareholders whose total shares added together is 2% of the total shares but each shareholder individually only holds 0.66% of the shares.

________ TOTAL PERCENTAGE (%) of corporation/business/LLC held by minor shareholder(s) that individually holds less than 1% of the total shares of the corporation/business/LLC.

ADDITIONAL OFFICER/SHAREHOLDER INFORMATION FOR

CORPORATION/BUSINESS/LLC THAT HOLD THE IFQ ONLINE ACCOUNT

1) If this IFQ online account is held by a business, then complete this section for EACH officer or partner associated with the business.
Provide the information for all officers or partners that are shown on your most recent annual report. If your business is structured as a corporation, identify all shareholders in the corporation that own at least 1% or more of the shares, as well as the percentage of all shares in the corporation held by each shareholder. Individuals holding less than 1% of the shares (minor shareholders) should not be individually listed. Total shareholders must equal 100%. For all provide position held in business, name, address, social security number, date of birth, and telephone number.

2) Check the appropriate box below to certify that the applicant is or is NOT a United States citizen or permanent resident alien.

Additional Officer or Shareholder Information

Check all that apply: President/CEO Vice President Secretary Treasurer Director/Manager Other ________________ Shareholder Percent (%) of corporation held: _______________________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name First Name Middle Name Suffix

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

SSN Date of Birth (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

Additional Officer or Shareholder Information

Check all that apply: President/CEO Vice President Secretary Treasurer Director/Manager Other ________________ Shareholder Percent (%) of corporation held: _______________________

Certify Citizenship Status:

The applicant IS a United States citizen or permanent resident alien.

The applicant IS NOT a United States citizen or permanent resident alien.

Prefix Last Name First Name Middle Name Suffix

Mailing Address Apt/Suite City State County/Parish Zip Code Country

Physical Address

Check if same as mailing address Apt/Suite City State County/Parish Zip Code Country

SSN Date of Birth (mm/dd/yyyy) Area Code Primary Phone Number

Select one: Home Work Cell

_________ MINOR SHAREHOLDERS - Check here if one or more of your shareholders each individually hold shares that total less than 1% of the total shares of the corporation/business/LLC. For example, there might be three shareholders whose total shares added together is 2% of the total shares but each shareholder individually only holds 0.66% of the shares.

________ TOTAL PERCENTAGE (%) of corporation/business/LLC held by minor shareholder(s) that individually holds less than 1% of the total shares of the corporation/business/LLC.

Last form revision 02/07/2013