Western Pacific Pelagic Squid Jig Permit Application

OMB Control No: 0648-0589
Expires: xx/xx/xxxx

U.S. DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
NATIONAL MARINE FISHERIES SERVICE

Pacific Islands Regional Office - SFD Permits
1845 Wasp Blvd., Bldg 176
Honolulu, Hawaii 96818
(808) 725-5000 · Fax: (808) 725-5215

WESTERN PACIFIC PELAGIC SQUID JIG PERMIT
Please Print Legibly. Items marked with * are required. Note required documents and instructions on page 2.
Non-refundable application processing fee of $48.00 required. Make check payable to Department of Commerce, NOAA.
*VESSEL NAME: _____________________________________________________________ *VESSEL OFFICIAL NO: _____________________

USCG or State registration number

*VESSEL LENGTH: ________________ (feet) Permit is required for vessels >= 50 ft LOA)

*RADIO CALL SIGN: _______________________

*PERMIT HOLDER: _____________________________________________________________________

__________________________

First, Middle, & Last Name or Business Name

*Taxpayer ID Number (EIN or SSN)

*DATE OF BIRTH (Individual) OR INCORPORATION (Business): _______________________________ (MM/DD/YYYY)
*CONTACT PERSON: ______________________________________________________________ TITLE: _____________________________
First, Middle, & Last Name, if not same as permit holder

Corporate officer, business owner, partner

*BUSINESS MAILING ADDRESS: ______________________________________________ ___________________
Street/PO Box

City

____

State

_____________
ZIP

*BUSINESS PHONE: (______) ___________________ CELL PHONE: (______) ___________________ FAX: (______) ___________________
EMAIL: __________________________________________________________
Under penalty of perjury, I hereby declare that I, the undersigned, am the applying permit holder, or authorized to certify this application on behalf of the
applying permit holder, and the information contained herein is true, correct, and complete to the best of my knowledge.

*APPLICANT: ___________________________________ ________________________________________
Printed Name of Person Submitting Application

Signature

*DATE: ____________________
(MM/DD/YYYY)

*APPLICANT TITLE: ___ Vessel owner, ___ Permit holder, ___ Corporate officer or partner, ___ Designated agent**, or ___ Other_____________
(Check only one)
*Application is for ___ a new permit or ___ a renewal? If renewal, previous permit number? ________________________
It is prohibited to file false information on any application for a fishing permit (50 CFR 665.15(b)).
Privacy Act Statement: Federal Regulations (at 50 CFR Part 665) authorize collection of this information. This information is used to verify the identity of the applicant(s) and to
accurately retrieve confidential records related to federal fishery permits. The primary purpose for requesting the Taxpayer Identification Number (EIN or SSN) is for the collection and
reporting on any delinquent amounts arising of such person’s relationship with the government pursuant to the Debt Collection Improvement Act of 1996 (Public Law 104-134). Personal
information is confidential and protected under the Privacy Act (5 U.S.C. 552a). Business information may be disclosed to the public.

(page 2)

OMB Control No: 0648-0589
Expires: xx/xx/xxxx

PAPERWORK REDUCTION ACT INFORMATION
Public reporting burden for this collection is estimated as follows: 15 minutes for the WP pelagic squid jig permit application and 2 hours for all permit denial appeals.
Each burden includes 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 aspects of this collection of information, including suggestions for reducing this
burden, to NMFS Pacific Islands Regional Administrator, 1845 Wasp Blvd., Bldg. 176, Honolulu, HI 96818.
This information is being collected to ensure accurate and timely records about the persons licensed to participate in fisheries under Federal regulations in the Pacific
Islands Region. This will enable NMFS and the Western Pacific Fishery Management Council to (a) determine who would be affected by changes in management; (b)
inform license holders of changes in fishery regulations; and (c) determine whether the objectives of the fishery program are being achieved by monitoring entry and
exit patterns and other aspects of the fisheries. The information is used in analyzing and evaluating the potential impacts of regulatory changes on persons in the
regulated fisheries as well as in related fisheries. Responses to the collection are required to obtain the benefit of a license for the fishery involved (ref. 50 CFR
665.13). Data provided concerning the vessel and/or business of the respondents are handled as confidential under the Magnuson-Stevens Fishery Conservation
and Management Act (Sec. 402(b)). Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject 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.

INSTRUCTIONS FOR APPLICATION:
Please print all information legibly. Illegible writing may cause delays or errors in permit processing.
Vessel Name: Write the vessel name that is marked on the vessel and/or listed on the US Coast Guard (USCG) certificate of documentation or state/territory vessel
registration form. If vessel is undocumented and has no name, please write N/A or None.
Vessel Official No.: Write the vessel’s USCG documented number or state/territory undocumented vessel registration number.
Vessel Length: Write the length overall as documented by the USCG or state/territory registration.
Radio Call Sign: Write the call sign registered with the FCC if available.
Permit Holder: Write the name of the person or business to whom the permit will be issued.
Taxpayer ID Number: For individuals, this is your Social Security Number (SSN); for businesses, this is the Employer Identification Number (EIN).
Date of Birth or Incorporation: Write the date of birth for individuals, or date of incorporation for businesses.
Contact Person, Business Address, Business Phone and other contact information: Write the contact person name, contact person title, permit holder’s mailing
address, and permit holder’s telephone number. These will be the address and phone number of record. In addition, please provide the cell phone number, fax
number, and email.
Applicant and Date: The new or renewing permit holder (if individual) or an officer or member of the business or corporation submitting the application must print
their name and write their signature. Write the full date (MM/DD/YYYY) when the application is signed.
Applicant Title: Check the role of the applicant. If the applicant is not the permit holder or an authorized representative of the business permit holder, then a written,
signed, and dated letter of authorization from the permit holder naming the applicant as a designated agent is required.
New or Renewal?: Check one. If this is a renewal, write the previous permit number associated with this vessel and permit holder.
REQUIRED DOCUMENTS: You must submit the following with the application form:
1) A copy of the vessel's current U.S. Coast Guard Certificate of Documentation (documented vessel) or registration certificate from a state/territorial agency
(undocumented vessel) showing the current vessel owner,
2) Payment by check or money order for the non-refundable application processing fee of $48.00, payable to Department of Commerce, NOAA, and
3) **A signed letter from the permit holder authorizing the applicant as the agent, if the applicant is acting as an agent for the permit holder.
An application that is lacking required information, vessel registration or documentation, or payment will be considered incomplete. An incomplete application will be
abandoned if it is not completed within 30 days after reception, and you must inform PIRO within 15 days of any change of information on the application form (50
CFR 665.13). It is prohibited to file false information on any application for a fishing permit (50 CFR 665.15(b)).
Mail application and all required documents to the address at the top left of page 1, or drop them off at the NMFS Honolulu Service Center, Pier 38, Honolulu, HI (MF, 8 am to 4 pm). Contact NMFS at [email protected] to inquire about availability of an online permit application.