Federal Permit/Certificate Application to Fish in Colomb

OMB No. 0648-0205 Form Approval Expires: 10/31/2014

U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS OFFICE, F/SER14

FEDERAL PERMIT/CERTIFICATE
APPLICATION TO FISH IN COLOMBIAN
TREATY WATERS

263 13th Avenue South
St. Petersburg, FL 33701
Toll Free 877/376-4877 (8:00 am - 4:30 pm ET)
727/824-5326 (8:00 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

FOR OFFICE USE ONLY
Reviewer's Initials and Date
Sanction Case Number if
Sanctioned
Expiration Date

Application ID

FOR OFFICE USE ONLY

REMEMBER TO SEND A COPY of your current (not expired) United States Coast Guard (USCG) Certificate of Documentation.
If we have a copy of your USCG Certificate of Documentation on file, it must not be expired. Do not send your original. We
cannot accept a bill of sale.

1. VESSEL INFORMATION
USCG DOCUMENTATION NUMBER

TOTAL HORSEPOWER

VESSEL NAME

Crew Size - Total number of crew,
Including the Captain

HULL COLOR

SUPERSTRUCTURE COLOR

YEAR BUILT

LENGTH (FEET)

NAME OF COMPANY THAT BUILT THE VESSEL

INTERNATIONAL RADIO CALL SIGN

DO YOU HAVE SAILS?

YES

NO

HOLD or FISH BOX CAPACITY
(Pounds of Harvest) How many pounds of
product can you bring to the dock when full?
HULL MATERIAL

HULL IDENTIFICATION or IMO NUMBER

FUEL DATA

PRODUCT
STORAGE (check
all that apply)

DIESEL
FIBERGLASS

GASOLINE

STEEL

OTHER (DESCRIBE)

HAILING PORT CITY

WOOD
HAILING PORT COUNTY OR PARISH

HAILING PORT STATE
CEMENT

GROSS TONS

NET TONS

OTHER
________________

Page 1

FUEL CAPACITY TOTAL GALLONS

ON ICE IN HOLD,
FISH BOX, ICE
CHEST, COOLER
ETC.,
FREEZER
LIVE WELL

Form Revision 12/18/2012

SECTION 2. INDIVIDUAL VESSEL OWNER(S) AND LESSEE INFORMATION
Copy this page as needed to provide the required information on all persons that own or lease this vessel.
Does your USCG Documentation or State Registration show the vessel owner as a person or persons?

YES - Use this Page
for the vessel owner(s).

NO - Skip this Page go
to the next page.

1) Please complete section 2a of this page for the owner of the vessel as shown on the USCG Certificate of Documentation or, if not documented, on the
state registration certificate. If the vessel is jointly owned, please enter the information for the managing (primary) owner.
2) Complete the section 2b of this page for a joint owner if the vessel is jointly owned by more than one person. If the vessel is leased, complete section 2b
for the person that is leasing the vessel from the vessel owner. You must submit information on each joint owner and for each lessee. If you need more
spaces for additional owners or lessees, copy the blank form or provide the required information on a separate sheet of paper.
3) Place an "X" in the Mailing Recipient block to indicate who will receive the permit and all related information. Please only mark one box.
4) If your vessel's state registration does not list all owners of the vessel, also provide a copy of the vessel's title, or other documentation from the appropriate
state agency that identifies all vessel owners.

Section 2a - Vessel Owner as shown on the USCG Certificate of Documentation, or for Undocumented vessels,
the State Registration.
If the Documentation or State Registration shows one person's name as the owner, list it here.
MAILING RECIPIENT All
- mail about this permit will go to the person listed in this section.

Mr/Mrs/Ms

Last Name

Tax ID # (SSN)

First Name

Suffix JR,SR,etc.

Middle Name

Date of Birth (MM/DD/YYYY)

Area Code

Phone Number

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Answer questions 1 and 2 before moving on to section 3.
1. Does your USCG Documentation or State registration show more than one person as the vessel owner?

YES - Use this
Page for the
vessel owner(s).

2. Is a person or persons leasing this vessel from the vessel owner
YES - Use section 2b for the vessel
lessee(s) information.

NO - It is a business, Skip section 2b and put
lessee information in section 3b.

NO - Do not fill out this
section unless the
vessel is leased.

NO - Skip section 2b.

Section 2b - Vessel Lessee OR Additional Vessel Owner as shown on the USCG Certificate of Documentation
or for undocumented vessels, the State Registration.
If the USCG Documentation, State Registration or title shows more than one person as the owner, provide the second person's
information here. If there are more than two persons, photocopy this blank page to provide additional information.

For LEASED Vessels:

Lease Start
Date:

Lease End
Date:

MAILING RECIPIENT All
- mail about this permit will go to the person listed in this section.
Mail is automatically sent to the lessee per regulations.

Mr/Mrs/Ms

Last Name

Tax ID # (SSN)

First Name

Date of Birth (MM/DD/YYYY)

Middle Name

Area Code

Suffix JR,SR,etc.

Phone Number

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Page 2

SECTION 3. BUSINESS VESSEL OWNER AND LESSEE INFORMATION
Copy this page as needed to provide the required information on all businesses that own or lease this vessel.
Does your USCG Documentation or State Registration show a business as the vessel owner?
Is a business leasing this vessel from the vessel owner?

YES - Use section 5b
for the vessel lessee(s).

YES - Use this Page
for the vessel owner(s).

NO - Go back to the
previous page.

NO - There is no lease involved skip section 5b.

1) Please complete section 3a if the owner is a business as shown on the USCG Certificate of Documentation or, if not documented, on the state registration
certificate. If the vessel is jointly owned by more than one business, please enter the information for the managing (primary) owner in section 3a.
2) Complete section 3b of this page if a business is a joint owner of the vessel. OR if the vessel is leased by a business, provide the information for the
business that is leasing the vessel from the vessel owner. You must submit information on each joint owner and for each lessee. If you need more spaces
for additional owners or lessees, copy the blank form or provide the required information on a separate sheet of paper.
3) Place an "X" in the Mailing Recipient block to indicate who will receive the permit and all related information. Please only mark one box.
4) If your vessel's state registration does not list all owners of the vessel, also provide a copy of the vessel's title, or other documentation from the appropriate
state agency that identifies all vessel owners.

Section 3a - Vessel Owner as shown on the USCG Certificate of Documentation, or for Undocumented vessels,
the State Registration.
If the Documentation or State Registration shows one business name as the owner, list it here. If there are two business's that
own the vessel, list the managing business in section 5a and the second business in section 5b.
MAILING RECIPIENT All
- mail about this permit will go to the business listed in section 5a.

Registered Name of Business

Tax ID # (FEIN)

Date Business Formed (MM/DD/YYYY)

Area Code

Phone Number

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Section 3b - Vessel Lessee or Additional Vessel Owner as shown on the USCG Certificate of Documentation
or for Undocumented vessels, the State Registration.
If the Documentation, State Registration or Title shows more than one business as the owner, provide the second owner's
information here. If there are more than two businesses, photocopy the blank page to provide additional information.

For LEASED Vessels:

Lease Start
Date:

Lease End
Date:

MAILING RECIPIENT All
- mail about this permit will go to the business listed in section 5b. Mail is automatically sent to the lessee as required by regulations.

Registered Name of Business

Tax ID # (FEIN)

Date Business Formed (MM/DD/YYYY)

Area Code

Phone Number

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Page 3

SECTION 4 . OFFICER/SHAREHOLDER INFORMATION FOR BUSINESS(ES) THAT OWN OR LEASE THE VESSEL
This page must be filled out if the owner or the lessee of the vessel is a business.
Copy this page as needed to provide information on all persons that are officers/shareholders of the business shown in Section 5.
Complete this section for each officer or partner associated with the business that owns or leases the vessel. You must provide the information for all
officers shown on your most recent annual report.

Owner or lessee of the vessel:

Owner

Lessee

Business name:

Federal Tax ID #

All individuals associated with the above-named vessel owner or lessee must be included in this application. Photocopy this page or attach additional sheets
as necessary to list all officers, directors, shareholders, and registered agents of the business. Provide their name, Social Security Number, address, phone
number, date of birth, and position held in business.
Position held - check ALL that apply
President/CEO

Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name

Director/Manager

First Name

Shareholder

Other

Suffix JR,SR,etc.

Middle Name

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (SSN)

Date of Birth

Area Code

Phone Number

Position held - check ALL that apply
President/CEO

Mr/Mrs/Ms

Vice President

Secretary

Treasurer

Last Name

Director/Manager

First Name

Shareholder

Other

Middle Name

Suffix JR,SR,etc.

Mailing Address

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Street Address (PO Box not acceptable)

Apt/Suite #

City

State

County/Parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (SSN)

Date of Birth

Area Code

Page 4

Phone Number

Section 5. ADDITIONAL INFORMATION
PRINCIPAL PORT OF LANDING OF THE FISH TO BE TAKEN FROM COLOMBIAN TREATY WATERS:

PRIMARY SPECIES OF FISH TO BE TAKEN FROM COLOMBIAN TREATY WATERS:

PRIMARY GEAR TO BE USED IN COLOMBIAN TREATY WATERS:

Section 6. SIGNATURE FOR APPLICATION - REQUIRED
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).
Please note: If the vessel listed in Section 1 is leased, the applicant who signs below must be an individual named as a lessee in Section 2, or an officer or
shareholder of the lessee as listed in Section 4. If the vessel listed in Section 1 is not leased, the applicant must be an individual named as an owner in
Section 2, or an officer or shareholder of the owner as listed in Section 4.
Applicant Signature

Position in Company

Date

Print Name

Public reporting burden for this collection of information is estimated to average 30 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.
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 other uses. Responses to this collection are required to obtain or
retain a fisheries permit under the Magnuson - Stevens Act. Name and address information will be released via a NOAA website. 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
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