Form 3-200-30 Federal Fish and Wildlife Permit Application Form

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		OMB No. 1018-0093 Expires XX/XX/2017
Return to: Division of Management Authority (DMA) U.S. Fish and Wildlife Service 4401 N. Fairfax Drive, Room 212 Arlington, VA 22203 1-800-358-2104 or 703-358-2104		Type of Activity: Export/Re-export/Re-import of Circuses and Traveling Animal Exhibitions (and Reissuance) (CITES/ESA) ___ New Application ___ Master File Permit #: _______________ ___ Requesting Re-issuance/Amendment of Permit#__________

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.

See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.

A.	Complete if applying as an individual
1.a. Last name			1.b. First name		1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)		3. Social Security No.	4. Occupation		5. Affiliation/ Doing business as (see instructions)
6.a. Telephone number		6.b. Alternate telephone number		6.c. Fax number	6.d. E-mail address

B.	Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution
1.a. Name of business, agency, Tribe or institution				1.b. Doing business as (dba) 
2. Tax identification no.			3. Description of business, agency, Tribe, or institution
4.a. Principal officer Last name			4.b. Principal officer First name				4.c. Principal officer Middle name/ initial		4.d. Suffix
5. Principal officer title 						6. Primary contact name
7.a. Business telephone number		7.b. Alternate telephone number			7.c. Business fax number			7.d. Business e-mail address

C.		Applicant address All applicants complete address information
1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City	1.c. State			1.d. Zip code/Postal code:		1.e. County/Province		1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City	2.c. State		2.d. Zip code/Postal code:		2.e. County/Province		2.f. Country

D.	All applicants MUST complete
1.			Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount identified on page 2. Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee – attach documentation of fee exempt status as outlined in instructions. (50 CFR 13.11(d))
2.		Do you currently have or have you ever had any Federal Fish and Wildlife permits? Yes  If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: _________________________________No 
3.		Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001. ________________________________________________________________________________________________________________________ Signature (in blue ink) of applicant/person responsible for permit (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)

Please continue to next page

E. Export/Re-export/Reimport of Circuses, Traveling Animal Exhibitions, or Museum Exhibitions

(and Reissuance) (CITES/ESA)

Note 1. This form is only for the purpose of temporary travel (export and re-import) to exhibit animals, museum exhibitions, or other traveling exhibitions where specimens do not change ownership (e.g., not being bought or sold while outside the United States). If you are intending to transfer ownership or offer specimens for sale outside the United States, submit form 3-200-23 (pre-Convention specimens) or 3-200-37 (ESA/CITES specimens). All applications can be found at http://www.fws.gov/international/permits/by-form-number/index.html.

Note 2. If you are traveling with musical instruments, you can use form 3-200-88 (Musical Instrument Certificate).

Note 3. For activities involving marine mammals, use form 3-200-53 (Export /Re-Export of Live Captive Held Marine Mammals (CITES)).

Note 4. If you are applying on behalf of a client, provide documentation to show that you have a Power of Attorney authorizing you to act on behalf of the client.

Note 5. For Re-issuance and Amendments requests: PLEASE RETURN THE ORIGINAL PERMIT.

Note 6. Please review the complete application before beginning. There are three scenarios under which circus and traveling exhibition are permitted.

Scenario 1. Traveling Exhibition Certificate (Resolution Conf. 12.3(Rev. CoP13)). This applies only to an animal or specimens that qualify as pre-Convention¹ or Bred in Captivity as defined in Resolution Conf. 10.16 (Rev.). A CITES certificate may be issued up to 3 years for a single animal or a group of (non-living) specimens. Follow instructions in Part I below, and complete one application per animal or group of specimens moving as one exhibition. If the animal or specimens do not qualify for the traveling-exhibition certificate, follow instructions in Part II. Processing fee: $100 for a species listed on both CITES and ESA; $75 for a species listed on CITES only.

Scenario 2. For animals that do not qualify under Scenario 1, a Master File can be established that is valid for up to three years for one or more animals or specimens. A Master file would authorize a number of (re-)exports and/or imports over a three-year period, but you would still be required to obtained CITES re-export documents for the re-exporting country before returning to the United States. Once a Master File is approved, you must obtain single-use permits, valid for 6 months or until the expiration of the master file, whichever is sooner, for each export/re-export or import (50 CFR 13.11). Processing fees: $200 to establish a Master file; $100 for Master file renewal; $5 single use documents. Follow instructions in Part II.

Scenario 3. For animals that do not qualify under Scenario 1 and you do not need/want to conduct multiple shipments, you may apply for a Single Use Permit for multiple animals that is valid for a single export or re-export. If you are making a single import, please use from 3-200-37. Processing fee: $100. Follow instructions in Part II.

Provide the following information. Complete all questions on the application. Mark questions that are not applicable with "N/A". You may need additional sheets of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. Please do not submit video tapes.

Complete either Part I or Part II, as appropriate AND Part III and IV.

Part I. Traveling Exhibition Certificate (Scenario 1)

1. Provide the following for the animal or group of specimens (a separate permit application is needed if more than one animal is involved).

Scientific name (genus, species, and if applicable, subspecies) and Common name	Gender, if known	Date of Birth or manufacturing (MM/DD/YYYY)	Source (Wild or Born in captivity)	Country of last re-export	Description (e.g., I.D. #, band #, tattoo #, tag #, size, microchip #, house name, distinguishing marks/features). If microchip #, provide manufacturer and location of microchip2. (Border officials must be able to verify that the permit and the animal correspond.)

2. Current location of specimen(s):

Part II. Animals or specimens that do not qualify for a Traveling-exhibition Certificate.

1. Please indicate which you are requesting (check appropriate box):

___ Master File (Scenario 2 - individual CITES documents, valid for up to six months, issued from the Master File)

How many single-use permits do you anticipate using in the next six months if master file is approved? _________. Additional CITES documents may be requested via form 3-200-74 (http://www.fws.gov/international/permits/by-form-number/index.html).

OR

___ Single Use Permit (Scenario 3) valid for a single shipment in a six-month period.

Indicate country and location(s) of exhibition:

Address:

City:

State or Province

Country:

Postal Code:

2. Provide the following for each animal or specimen (multiple animals or specimens may appear on a single document).

Scientific name (genus, species, and if applicable, subspecies) and Common name	Gender, if known	Date of Birth or Manufacturing (MM/DD/YYYY)	Source (Wild or Born in captivity)	Last Country of last re-export	Description (e.g., I.D. #, band #, tattoo #, tag #, size, microchip #, house name, distinguishing marks/features). If microchip #, provide manufacturer and location of microchip3. (Border officials must be able to verify that the permit and the animal correspond.)

3. Current location of specimens:

Part III (All applicants complete). For EACH animal or specimen, provide the following. If your application covers more than one animal or specimen, be sure to answer questions 1 and 2 for each animal or specimen being addressed in the application.

If this animal or specimen qualifies as pre-Convention¹, provide documents, signed statements or other evidence that the wildlife was born or removed from the wild prior to the date CITES applied to it (e.g., bill of sale, ISIS record, breeder's record).

1. Was the animal or source of the specimen born/hatched in captivity? Yes ___ No ____.

If YES, provide responses to a and b. below:

a. Are you the breeder? If so, please provide a statement that the animal was bred and born/hatched at your facility. This statement must include:

i. Birth/hatch date, and if applicable band/tag number, and sex of each specimen;

ii. Name and address of your facility where the animal was bred and born;

iii. Location of parental stock; and

iv. Your signature and date.

b. If you are NOT the breeder of the specimen(s), provide copies of documentation showing that you acquired the animal from the breeder or documentation demonstrating the history of transactions (chain of ownership of each animal) and a signed statement from the breeder or breeder's record that includes:

i. That the animal was bred and born/hatched at his/her facility;

ii. Birth/hatch date, and, if applicable, band/tag number, or other identifiers;

iii. Sex of each specimen;

iv. Location (Name, Street address, City, State) of Parental Stock;

v. Complete name and address of the breeder's facility.

If NO (animal was not born/hatched in captivity), provide:

i. Location of where, when, and by whom (name and address) the specimen was removed from the wild;

ii. Purpose of removal;

iii. Copy of any permits or other documents from the State or local wildlife authorities approving the activities;

iv. Documentation showing that the specimens were legally acquired by the applicant; and

v. Copies of any applicable State permits or licenses that are required to house, maintain, and breed these specimens (contact your State for information).

2. If this animal or animal from which the specimen was obtained is protected by the U.S. Endangered Species Act (ESA):

Is the animal or specimen pre-Act (acquired or held in a controlled environment on or before (a) December 28, 1973 or the date when the species was listed, and (b) has not entered into commerce (e.g., been bought, sold, or offered for sale by you or anyone else) since December 28, 1973, or the date when listed)?

a. ___ If yes, provide evidence that the animal meets the above criteria.

b. ___ If no, you must be able to show that your proposed activity would meet the issuance criteria under ESA. For endangered species, permits can be issued for activities that enhance the survival or propagation of the species or scientific research. For threatened species, permits can be issued for the above reasons, as well as education, zoological display, or other purposes that would meet the purpose of the Endangered Species Act.

Provide a statement, and documentation to support the statement, on how the activities will enhance or benefit the wild population (in-situ and ex-situ projects). While permits cannot be issued solely for educational or display purposes for endangered species, if your activities include conservation education, provide copies of educational materials (e.g., handouts, text of signage or public presentations). If you are submitting more than one application at this time for a group of animals, you can complete this section on one application and refer any subsequent application to this statement. If you need more explanation on this question, please contact the Division of Management Authority.

3. (For all applicants) If your activity includes public presentations, please provide the following:

i. In what type of presentation are you proposing to use the specimen (e.g., live performance, movie, TV)?

ii. Provide a copy of the actual script or material that will be presented to the audience at each performance, show, or viewing of the specimen(s). This material must be original in nature (e.g., photocopies from a reference book are not appropriate) and must be the actual material that will be presented each time the animal is viewed by the target audience.

3. Will fact sheets, brochures, or posters be used? Is the written material available free-of-charge?

4. When will the material be presented? If the material will be presented orally, when will this presentation be given? What activities will be occurring at the same time the presentation of the message is being provided and could the activity diminish the effectiveness of the presentation? If the material will be presented in a written form, will an oral announcement be made regarding the availability of this material? If the material is in poster form, will the posters be placed so that the material will be accessible by the public?

5. When exhibiting in countries where English is not the primary language, explain how the conservation education information will be presented to the non-English speaking audience.

4. Is the animal a live non-human primate? If so, provide a copy of your current Centers for Disease Control (CDC) registration.

Part IV (all applicants complete). If you are submitting more than one application at this time, you may submit the following information once and refer to it in all subsequent applications.

1. For live exhibitions, provide the following on your facilities:

a. Provide address of the permanent facility where the animal(s) is/are maintained.

Name of Facility

Address

City, State, Zip code

b. A detailed description, including size, construction materials, protection from the elements, and photographs or detailed diagrams clearly depicting the permanent facilities;

c. Provide the same as above for transportation units used while traveling within the United States and abroad. The transport conditions must comply with 50 CFR Part 13, the CITES Guidelines for Transport of Live Animals, as well as the Animal Welfare Act and, in the case of air transport, with the International Air Transport Association (IATA) (www.iata.org/cargo/live.htm) live animal regulations. Your description must include:

i. The type, size, and construction of any shipping container; and

ii. The arrangements for watering or otherwise caring for the wildlife during transport.

d. Description of the qualifications of the individuals to train and care for the animal, including the number of years’ experience with this species or similar species, and names of current caretakers.

2. For live exhibitions, provide a list all mortalities of ESA listed species which occurred at your facility during the past five years, and explain the cause of the mortalities and measures taken to prevent future mortalities if appropriate.

3. Provide copies of any applicable permits, licenses and registrations (State Fish and Game, U.S. Department of Agriculture Animal Welfare Act (AWA), Center for Disease Control and Prevention).

4. All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. If you wish to use a port not listed, please contact the Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).

5. Name and address where you wish permit mailed, if different from page 1 (All permits will be mailed via the U.S. Postal Service, unless you identify an alternative means below):

6. If you wish the permit to be delivered by means other than USPS regular mail, provide an air bill, pre-paid envelope, or billing information. If you do not have a pre-paid envelope or air bill and wish to pay for a courier service with your credit card, please check the box below. Please DO NOT include credit card number or other information; you will be contacted for this information.

□ If a permit is issued, please send it via a courier service to the address on page 1 or question 5. I understand that you will contact me for my credit card information once the application has been processed.

7. Who should we contact if we have questions about the application? (Include name, phone number, and email):

8. Disqualification Factor.  A conviction, or entry of a plea of guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird Treaty Act, or the Bald and Golden Eagle Protection Act disqualifies any such person from receiving or exercising the privileges of a permit, unless such disqualification has been expressly waived by the Service Director in response to a written petition.  (50 CFR 13.21(c))  Have you or any of the owners of the business, if applying as a business, been convicted, or entered a plea of guilty or nolo contendere, forfeited collateral, or are currently under charges for any violations of the laws mentioned above? 

 

___  Yes     ___  No    If you answered “Yes” provide: a) the individual’s name, b) date of charge, c) charge(s), d) location of incident, e) court, and f) action taken for each violation.  

APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an U.S. Fish and Wildlife Service (FWS) permit applications. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates are referred to as a permit.

GENERAL INSTRUCTIONS:

• Complete all relevant questions in Sections A or B, C, D, and E.

• An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate application form for the proposed activity.

• Print clearly or type in the information. Illegible applications may cause delays.

• Sign the application in blue ink. Faxes or copies of the original signature will not be accepted.

• Mail the original application to the address at the top of page one of the applications or, if applicable, on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 60 days for your application to be processed, however, some applications may take longer than 90 days to process (50 CFR 13.11).

• Applications are processed in the order they are received.

SECTION A OR SECTION B:

Section A. Complete if applying as an individual [do not complete this section if applying for Import/Export License (3-200-3)]:

• Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the applicant. Fax and e-mail, while helpful in processing, are not required.

• If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be included with the application.

• Affiliation/ Doing business as (dba): business, agency, organizational, Tribe, or institutional affiliation directly related to the activity requested in the application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division of Management Authority (DMA) and the Office of Law Enforcement (OLE) do not accept doing business as affiliations for individuals (complete Section B)..

Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:

• Enter the complete name of the business, agency, or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the applicant is engaged in. Provide contact phone number(s) of the business. If you are applying on behalf of a client, a document evidencing power of attorney must be included with the application.

• Principal Officer is the person in charge of the listed business, corporation, public agency, Tribe, or institution. The principal officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at the business, corporation, public agency, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted to the Division of Management Authority (DMA) and Office of Law Enforcement (OLE), a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs that use foreign addresses and are not required by DMA.

• Mailing address is the address to which communications from USFWS should be mailed if different from applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is required at the time of application, unless exempted under 50 CFR13. The application processing fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit, nor will fees be refunded for applications for which processing has begun.

• Documentation of fee exempt status is not required for applications submitted by Federal, Tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Such applications must include a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most recent issued USFWS permit. If applying for re-issuance of a CITES permit, the original permit must be returned with this application.

Section D.3 CERTIFICATION:

• The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation must be included in the application) must sign and date the application in blue ink. This signature legally binds the applicant to the statement of certification. You are certifying that you have read and understand the regulations that apply to the permit. You are also certifying that all information included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:

1. The gathering of information on fish and wildlife is authorized by:

(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.html

a. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;

b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50 CFR 17;

c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;

d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;

e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;

f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;

g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/ , 50 CFR 23;

h. General Provisions, 50 CFR 10;

i. General Permit Procedures, 50 CFR 13; and

j. Wildlife Provisions (Import/export/transport), 50 CFR 14.

2. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. We may not conduct or sponsor and you are not required to respond to collection of information unless it displays a currently valid OMB control number.

3. Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972 (16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4. Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)

a. Routine disclosure to subject matter experts, and Federal, Tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records.

b. Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the decision on a permit application.

c. Routine disclosure to Federal, Tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all applicable permitting requirements.

d. Routine disclosure to Captive‑bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive breeding of these species.

e. Routine disclosure to Federal, Tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.

f. Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or administrative body, under certain circumstances.

g. Routine disclosure to the appropriate Federal, Tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or regulated use.

h. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.

i. Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.

j. Routine disclosure 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 FWS.

5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application.

6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for an Export/Re-Export/Re-import of Circuses and Traveling Animal Exhibitions (and Reissuance) application is 60 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 2042-PDM, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.

Freedom of Information Act – Notice

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].

DO NOT RETURN THIS PAGE WITH THE APPLICATION

1 Specimen was acquired (removed from the wild or held in captivity or a controlled environment) before the date CITES applied to it. The listing date can be found http://www.cites.org. CFR 23.45 b1

2 The exporter may be asked to have a microchip reader on hand to read the microchip at the time of export.

3 If a microchip is used to identify the animal, the exporter may be asked to have a microchip reader on hand to read the microchip at the time of export.

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