Form 3-200-39a Certificate of Scientific Exchange (COSE) Special Report

U nited States Department of the Interior

FISH AND WILDLIFE SERVICE

Washington, D.C., 20240

OMB No. 1018-0093

Expires: XX/XX/2017

__US________/_

CERTIFICATE OF SCIENTIFIC EXCHANGE (COSE)

SPECIAL REPORTING CONDITIONS

Permittee: _______________________________

Reporting Requirements. Annually, permittee must provide a report to the Division of Management Authority, 4401 N. Fairfax Drive, Rm. 212, Arlington, VA, 22203. This report must describe all exchanges of specimens that occurred in the preceding calendar year and made under the registered scientific institution system under the COSE [CITES Resolution Conf. 11.15 (Rev. CoP12)]. A suggested format is described below. Non-activity must also be reported. If reports are not received annually, the CITES registration is subject to revocation.

Outgoing Specimen Report

Date Sent	Description of specimen	Accession or Record no.	Scientific name and common name	Receiving institution, Country	COSE Code No.

Incoming Specimen Report

Date Received	Description of specimen	Accession or Record no.	Scientific name and common name	Originating institution, Country	COSE Code No.

In addition, permittee must maintain complete and accurate records of any specimens imported or exported under this Certificate (50 CFR 13.46). The records must be kept current and should include the name, address, and COSE number of the institution sending or receiving specimen(s), a description of the specimen(s) exchanged, and the date the exchange occurred. The records must be maintained for five years from the date of expiration of the Certificate. The permittee must make the records available to US Fish and Wildlife Service employees for inspection upon request.

FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act – Notice

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.), 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. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form.

3. The relevant burden for the report conditioned by an issued Export and Re-import of Museum Specimens permit is 30 minutes. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the report. You may direct comments regarding the burden estimate 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.

DO NOT RETURN THIS PAGE WITH THE APPLICATION

Form 3-200-39a Rev. 02/2014 Page 2 of 2