Form 3-2355 Waterfowl Lottery Application

U.S. Fish and Wildlife Service Waterfowl Lottery Application

_{National Wildlife Refuge System}

OMB Control Number

1018-0140

Expires x/xx/201x

Follow instructions in the refuge hunt publication; all fields may not be required. Read and comply with all refuge regulations, including application deadlines.

1. Name of Refuge

_{2. Date of application}

_{3. Full Name}

Area Code/Phone No.

_{Mailing Address}

_{City, State, ZIP}

_e-mail

4. Hunt Date Choices

1st Choice

2nd Choice

5. Hunt Location Choices

1st Choice

2nd Choice

3rd Choice

3rd Choice

4th Choice

4th Choice

5th Choice

5th Choice

6. Special Hunt

_{6A. Youth Hunt Only: Age at time of hunt}

7. I have read and understand the refuge hunt regulations and agree to abide by the regulations governing hunting on the refuge.

Hunter signature Print Guardian name and signature here (required for hunters less than 18 years of age)

For Office Use only:

Payment Exempt/No fee

Payment required

Date Received

_{Payment Type:}

Amount:

Personal Check

Cashiers Check

Notes

Money Order Other

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:

1. The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System is 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).

2. The information that you provide is voluntary; however submission of requested information is required to evaluate the qualifications, determine eligibility, and document permit applicants under the above Acts. It is our policy not to use your name or email for any other purpose. The information is maintained in accordance with the Privacy Act. All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the 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.

3. We estimate the public reporting burden on the applicant for information collection to be 30 minutes. 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 BPHC, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.

4. Routine use disclosures may 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 (48 FR 54716; December 6, 1983).

5. 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. This information collection has been approved by OMB and assigned control number 1018-0140.

FWS Form 3-2355

REV xx/15