Observer/catch monitor provider renewal application

OMB Control No. 0648-0619; Expiration Date: 11/30/2014

Observer/Catch Monitor Provider Permit Renewal Form Pacific Coast Groundfish Individual Fishing Quota

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

Section A – Applicant Information
Permit Number:			End Date:
1. Legal Name of Applicant				2. TIN (if business) or DOB (if person)
				3. State Registered In (if business)
4. Business Mailing Address Street or PO Box				5. Business Phone Number ( )
				6. Business Fax Number (optional) ( )
City	State	Zip Code		7. Business Email (optional)
Section B – Current Endorsement(s) [If you require an additional endorsement, you must submit a new application]
Observer Endorsement Catch Monitor Endorsement

Section C – Ownership/Employees/Management And Organization Structure
List All Owners of Applicant Entity Below
Name			Date of Birth
1.
2.
3.
4.
5.
6.
List All Current Employees
Name	Date of Birth	Job Title
1.
2.
3.
4.
5
6.
7.
8.
List Board Members (if applicable) below: Name	Date of Birth
1.
2.
3.
Please attach a written narrative that further describes the organization and management structure of the entity applying for this permit.

Section D – Conflict of Interest Certification

Under penalty of perjury, I affirm that all owners, board members, officers and employees of the applicant have no indirect or direct financial interest in commercial fishing, processing, seafood brokerage operations in the United States.

Indicate whether you affirm/do not affirm the statement above by checking the appropriate box below

I AFFIRM [ ]

I Do NOT Affirm [ ]

Section E – Criminal Convictions, Negative Performance Ratings on
Federal Contracts and Decertification Actions

Under penalty of perjury, I affirm that all owners, board members, officers of the applicant have satisfactory performance on any Federal contracts held by the applicant and have not criminal convictions related to: embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement, receiving stolen property or commission of any other crimes of dishonesty as defined by U.S. state or Federal law that would seriously and directly affect the fitness of the applicant.

I also affirm no owners, board members, or officers of the applicant that have been decertified as an observer or catch monitor under provisions in §§ 660.18(e), and 660.140(h)(6), 660.150(j)(6), 660.160(g)(6) or 679.53(c).

Indicate whether you affirm/do not affirm the statement above by checking the appropriate box below

I AFFIRM [ ]

I DO NOT AFFIRM [ ]

Section F – Certification of Applicant and Notary This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative
Notary Public Signature  ATTEST	Affix Notary Stamp or Seal Here
Date Commission Expires
WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil penalty of up to $140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001. PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of this collection. The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065). PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing the 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 aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and released to the public.

OMB Control No. 0648-0619; Expires: 11/30/2014

Observer/Catch Monitor Provider Permit Renewal Form Pacific Coast Groundfish Individual Fishing Quota

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

INSTRUCTIONS

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to renew a provider permit. The provider permit authorizes an entity to provide observer and/or catch monitors to participants in the Pacific Coast Groundfish fishery trawl rationalization program. The permit is effective upon approval by NMFS.

Section A – Provider Information

This section displays the current provider information of record with NMFS. Please review the information for accuracy. If the permit holder has changed ownership, a new application must be provided. If necessary, please update business mailing address, business phone number and fax number and email address by crossing out the incorrect information and printing the updated information. .

Section B – Current Endorsements

This section displays the endorsement (observer and/or catch monitor) registered to your permit. As part of renewal, you cannot add an endorsement. To add endorsement, you must submit a new application that specifically requests the other endorsement.

Section C – Ownership/Employees/Management and Organization Structure

Please review the list of owners, employees and board of directors (if applicable). If the list is not current, please make changes as appropriate. If individuals have left the organization place a line through the name of the individual. If an individual has been added, please write in the person’s name and provide other information as required (i.e.; date of birth, title). If there are any significant changes [ ] in the management and organizational structure of the provider entity since your last application to NMFS, please prepare a statement that confirms there is no change. If there has been a change, please submit a revise your prior narrative and submit with this form.

Section D – Conflict of Interest Certification

Please review the statement and indicate whether you affirm or do not affirm the statement by checking the appropriate box. One box must be checked for the application to be considered complete.

Section E – Criminal Convictions, Negative Performance Ratings on Federal Contract and Decertifcation Actions

Please review the statement and indicate whether you affirm or do not affirm the statement by checking the appropriate box. One box must be checked for the application to be considered complete.

Section F – Certification of Applicant and Notary

The provider or authorized representative must sign and date this form in the presence of a notary to certify that the individual signing the form have satisfactorily identified themselves. By signing and dating the form, the authorized representative acknowledges they are authorized to make the certification on behalf of the provider, and certifies that all information set forth in the form is true, correct and complete to the best of their knowledge and belief. The authorized representative must print their name. The form must be signed, dated and notarized to be considered complete.