Form 3-200-37 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/IMPORT/INTERSTATE AND FOREIGN COMMERCE/TAKE OF ANIMALS (Live/ samples/parts/products) (ESA and/or CITES) (circle/highlight proposed activity) ___ New Application ___ Requesting Re-issuance/Amendment of Permit#: _____________

Complete Sections A or B, and C through H 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 of $100 nonrefundable processing fee. 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)

E. EXPORT/RE-EXPORT/IMPORT/INTERSTATE AND FOREIGN COMMERCE/TAKE OF NON-NATIVE ANIMALS (Live/samples/parts/products) (CITES and/or ESA)

Allow at least 90 days for the application to be processed. Applications for endangered species permits must be published in the Federal Register for a 30-day public comment period.

Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If you are applying for multiple specimens, be sure to indicate which specimen you are addressing in each response.

1. What activity are you requesting authorization to carry out (Indicate appropriate activities):

EXPORT _____ IMPORT _____

INTERSTATE COMMERCE _____  FOREIGN COMMERCE _______

*Interstate Commerce permits authorize the sale of endangered and threatened species across State lines, but only for that will contribute to enhancing the propagation or survival of that species. Captive-breeding alone will not generally meet this requirement. Scientific research must be related to the species to be permitted. Interstate commerce activities with wildlife require the buyer to obtain a permit prior to the sale.

2. For EACH animal/specimen involved in the proposed activity provide:

Scientific name (genus, species, and, if applicable, subspecies)	Common Name	Birth/Hatch Date (mm/dd/yyyy) Or Approximate date	Quantity	Gender, if known	Permanent markings (e.g., tattoo, ID #, microchip #, scars), if alive	Type of Sample or product (e.g., blood, tissue, DNA)
EXAMPLE: Macaca fascicularis	Crab-eating macaque

3. The current location of the specimen(s) (address and country):

Name:

Address:

City:

State/Providence:

County, Postal Code:

4. Recipient/Sender:

• If export, provide name and address of the recipient in the foreign country.

• If import, provide name and address of the exporter in the foreign country.

• If interstate or foreign commerce, provide name and address of recipient.

Name:

Address:

City:

State/Providence:

County, Postal Code:

F. SOURCE OF SPECIMEN (answer question 5 or 6 for each animal/specimen involved, as appropriate).

5. For each animal or animal from which specimen are obtained born in captivity:

a. If you are the breeder of the specimen(s), please provide a signed and dated statement that includes the following:

i. Scientific name (genus, species, and, if applicable, subspecies) and common name;

ii. That the animal was bred and born at your facility;

iii. Birth/hatch date (mm/dd/yyyy), and, if applicable, identification information (as described in question 2b above);

iv. Name and address of your facility where each animal was bred and born; and

v. Location (Name of facility, address, city, State/province, postal code) of parental stock.

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 (e.g., chain of ownership of the animal) and a signed and dated statement from the breeder or breeder's record that clearly includes the following:

i. Scientific name (genus, species, and, if applicable, subspecies) and common name;

ii. That each animal was bred and born/hatched at his/her facility;

iii. Birth/hatch date (mm/dd/yyyy), and, if applicable, identification information (as described in question 2b above);

iv. Name and address of the breeder’s facility; and

v. Location (name of facility, address, city, State/province, postal code) of parental stock.

6. For each animal/specimen taken from the wild, provide the following:

a. Scientific name (genus, species, and, if applicable, subspecies) and common name;

b. Specific location of where, when, and by whom (name and address) the specimen was removed from the wild;

c. Purpose of removal and length or approximate length of time held in captivity;

d. Describe your efforts to use captive specimens (e.g., captive-born, captive-held), or parts thereof, in lieu of taking animals from the wild.

e. Copies of your foreign or domestic collecting permit, license, contract or agreement;

f. Documentation showing that the specimen(s) was legally obtained by the applicant; and

g. Copies of any applicable State, Tribal, Federal, or Foreign government permits or licenses that authorized the removal of this animal from the wild.

G. JUSTIFICATION FOR REQUESTED ACTIVITY.

7. Provide a full statement justifying the proposed activity, particularly the following:

a. Describe the purpose of your proposed activity. For example, if the purpose is scientific research, attach a copy of your research proposal outlining the purpose, objectives, methods (e.g., specific information on survey/collection methods, sampling regime, equipment to be used), and whether similar work has already been done or is currently being done. If the purpose is conservation education, provide copies of educational materials (e.g., handouts, text of signage or public presentations), and include the purpose and objectives of the proposed activity. If the purpose is for propagation for conservation purposes, provide a description of how the species will be propagated, disposition of progeny, and cooperative agreements that are/will be established for re-introduction.

b. Description of the technical expertise of each person (please include CV or resume), as it relates to the proposed activities. If the proposed activity involves the import of live animals, include the experience of each animal caretaker working with the species.

c. Copies of contracts, agreements or other documents that identify persons involved and dates of activities for which authorization is being requested.

8. A statement on how the activities will enhance or benefit the wild population (e.g., in-situ and ex-situ projects).

9. If live specimens are to be held in captivity as part of the proposed activity:

a. Provide a detailed description (e.g., size, construction materials, protection from the elements) and photographs or diagrams (no blueprints, please) clearly depicting the existing facilities where the wildlife will be maintained. If the specimens will be housed at multiple facilities, either immediately or within the next year, provide a full description of each facility. If you are unsure of which facilities may be receiving specimens (e.g., SSP has not made final decision), please indicate likely candidates and the mechanism that will be used to determine recipient facilities.

b. A statement of the specific technical experience of CV or resume available to the recipient(s) for maintaining and propagating live specimens of the same or similar species.

c. The number of years each species has been maintained at the facility;

d. The number of births by year for each species for the last 5 years; and

e. Mortalities at the facility with these or similar species in the last 5 years, causes of such mortalities, and steps taken to avoid or decrease such mortalities.

H. IMPORTS, EXPORTS, OR RE-EXPORTS.

10. For shipment of LIVE specimens, the transport conditions for animals must comply with the CITES Guidelines for Transport of Live Animals or, in the case of air transport, with the International Air Transport Association (IATA) live animal regulations (contact airline for information). As such, describe:

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

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

11. For import of LIVE CITES Appendix-I marine mammal specimens, provide a copy of your FWS or NOAA Fisheries permit or authorization.

12. For import of CITES Appendix-I listed species, provide information to show the import is not for primarily commercial purposes as outlined in Resolution Conf. 5.10 (www.cites.org).

13. For export of CITES Appendix-I species, provide a copy of the CITES import permit, or evidence one will be issued by the Management Authority of the country to which you plan to export the specimen(s). In accordance with Article III of the CITES treaty, it is required that import permits are issued before the corresponding export permit.

14. If the specimen is being re-exported (e.g., exporting a specimen that was previously imported into the United States), provide:

a. A copy of the canceled CITES export or re-export document issued by the appropriate CITES office in the country from which the wildlife was imported (if applicable); and

b. A cleared copy of Form 3-177, wildlife Declaration for Import (hard copy or electronic release); or

c. If you did not make the original import, provide a copy of the importer's documents outlined above and the invoice or other documentation that shows you acquired the wildlife from the original importer or history of transactions which demonstrate chain of ownership.

15. 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).

16. 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):

17. 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 11. I understand that you will contact me for my credit card information once the application has been processed.

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

19. 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), 50CFR 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 a 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/Import/Interstate and Foreign Commerce/Take of Animals application is 2 hours. 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

Form 3-200-19 Rev. <<Date>> Page 1 of <<#>>