Form 3-200-43 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: Take/Import/Transport/Export of Marine Mammals or Renewal/Amendment of Existing Permit (MMPA and/or ESA)  Requesting Renewal/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

5. Take/Import/Transport/Export of Marine Mammals or Renewal/Amendment (MMPA and/or ESA)

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

Note 1:

• This application is for the take, import, transport, export, or re-export of marine mammal species under the jurisdiction of the Fish & Wildlife Service (sea otters, marine otters, polar bears, walrus, manatees, and dugongs; http://www.fws.gov/international/pdf/factsheet-marine-mammal-policy-2013.pdf) and for the renewal and/or amendment of an existing permit.

• This application can also be used to apply for and renew a letter of authorization under MMPA Sections 109(h)/112(c) for the purpose of rescuing, rehabilitation, and release of stranded marine mammals.

• For activities involving photography in the wild, use Form 3-200-86.

• For transport/transfer of live captive-held animals within the U.S. use Form 3-200-87.

Note 2: If you already have MMPA/ESA authorization and need a CITES permit:

• For CITES export/re-export of captive-held LIVE animals, use Form 3-200-53.

• For, export, or re-export of parts or biological samples, use Form 3-200-29; for import of parts from Appendix I animals use Form 3-200-37; and for introduction from the sea, use Form 3-200-31.

• Provide a copy of your FWS or NOAA Fisheries permit or authorization with your CITES permit application. (All forms can be found at www.fws.gov/forms.)

Purpose (check below):

 ___PUBLIC DISPLAY (Processing Fee = $300): Answer questions: 1-24, 28-34 (as applicable), 43 - 47. Please note that a public display permit is not available for marine mammal species listed as depleted under the MMPA or listed under the ESA; a public display permit may be valid for the life of an animal and is not renewable; a public display permit may be available for a facility that would hold multiple animals of a particular species and would be renewable every 5 years.



___SCIENTIFIC RESEARCH (Processing Fee = $150): Answer questions: 1-32 (as applicable), 35 – 39, 43-47.



___ENHANCEMENT of survival or recovery (Processing Fee = $150): Answer questions: 1-32 (as applicable), 40-42, 43-47.



___LETTER OF AUTHORIZATION for rescue, rehabilitation, or release (RRR) of stranded marine mammals (Processing Fee = $150): Answer questions: 1 (take and transport), 2, 3, 6, 7, 9 - 14, 20 – 24, 28 – 32, and 43 – 47, and indicate the requested level(s) of responsibility (check all that apply):

___VERIFIER; ___RESCUER; ___TRANSPORTER; ___CRITICAL CARE FACILITY; ___REHABILITATION/HOLDING FACILITY

___RENEWAL of Permit # ____________

(See processing fees above; provide answers to all appropriate questions.)

___AMENDMENT of Permit # ____________

(Processing Fee for amendment of a Scientific Research, Enhancement permit, or RRR authorization = $75; Public Display = $150)

Complete all pages of the application. Mark questions that are not applicable with "N/A". If needed, use a separate sheet of paper and indicate the application question number you are addressing. If you are applying for multiple specimens, be sure to indicate which specimen(s) you are addressing in each response.

Electronic submission of inventories, photographs, and receipts: You may provide electronic versions of these documents. You may include a disk containing your information or, check here ­­­___ if you wish to provide the electronic documents via e-mail.

1. Type of activity requested (check all that apply):

___ TAKE ___ IMPORT ___ EXPORT

___ Live animal TRANSPORT ___ AMEND current permit ___ RENEW permit

(If you are requesting renewal or amendment of an existing permit between reporting dates, include an update of any activity that has occurred under the permit since the last report.)

2. List the scientific name (genus, species, and, if applicable, subspecies), common name, and quantity (e.g., 2 animals; or 20 samples per year per animal from 2 animals) for each species you are applying.

3. For each specimen of each species listed in question 2, provide the following. You may provide the information in tabular form:

Species

Birth date or age class*

Description (e.g. ID #, ISIS #, tattoo #; or if biological samples, the type of samples and size of containers)

Country of origin

Origin of the wildlife (wild, captive-born, or captive-bred)

Current location of specimens

* if describing age classes as “cub/pup/calf,” “juvenile”, “adult”, then explain the ages that constitute the age classes

SOURCE of Specimen(s). For each specimen, respond to the appropriate question:

4. For captive-born animals, provide a breeder’s statement, ARKS/ZIMS specimen report, or other information that documents the animal was born in captivity, location of birth, and information on the source of the parental stock (e.g., captive-born, wild-caught).

5. For captive-held animals taken from the wild, provide information (e.g., ARKS/ZIMS specimen report(s)) on the source of the animals, including when the specimen was removed from the wild, by whom, and the location. Include copies of all relevant permits or authorizations needed for the removal and placement in captivity.

6. For animals taken or to be taken from the wild, provide information on the actual or proposed date(s) and location(s) of collection and estimate of the species population stock (if known). In addition, provide a description of the efforts made to utilize captive animals or parts thereof, in lieu of taking animals from the wild.

TAKE and/or HARASSMENT of wild animals OR SAMPLING of captive-held animals. For each specimen that will or may be taken or harassed by your proposed activity, respond to the following questions.

7. Provide a description of the specific activities (e.g., survey, capture, tag, radio tag, kill) to which each animal will be subjected, the maximum number of animals taken each year and the number of takes per animal per year. Also estimate the number of animals incidentally harassed during each activity. This information may be provided in table format such as:

Species	Activity/Type of Take	Level A or Level B Harassment*	Max. # Animals/Year	Max. # Takes/Animal/Year	# Animals Incidentally Harassed (Level B harassment)

* Level A harassment means any act of pursuit, torment, or annoyance which has the potential to injure a marine mammal or marine mammal stock in the wild. Level B harassment means any act of pursuit, torment, or annoyance which has the potential to disturb a marine mammal or marine mammal stock in the wild by causing disruption of behavioral patterns, including, but not limited to, migration, breathing, nursing, breeding, feeding, or sheltering.

8. If the proposed activities involve intentional lethal takes, provide a justification as to why non-lethal alternatives are not feasible.

9. Provide an estimate of the possible number of non-intentional deaths or serious injuries, the number of any accidental deaths or serious injuries requested, and the steps you will take to reduce the likelihood of deaths or injuries.

10. If this species is protected under the Endangered Species Act (ESA):

a. Attach a justification for taking an ESA-listed species, and explain why your proposed activities are not appropriate for a similar non-ESA-listed species; and

b. Describe how the proposed activities will enhance or benefit the wild population.

11. Provide a list of the names and the responsibilities and duties of all personnel involved in the proposed activities and a copy of each person’s curricula vitae (CV). See also questions 29 and 38.

12. If biological samples are to be collected, provide:

Species

ID #

Gender

Source (Wild or Captive/Live or Dead)

Birth Date or age class

Type of Samples (blood, tissue, DNA)

Size/number of samples & how Packaged

Collector’s name and affiliation

Use/Disposi-tion of Samples

13. List your activities which will or may cause TAKE or HARASSMENT of TARGET species, and provide a written protocol that describes each of your activities. Please include:

a. The number of animals of each species that may be taken and harassed, the precautions that will be taken to minimize the likelihood that harassment will occur, and the actions that will be taken should harassment occur;

b. The times of year and the proposed dates that the takes would occur, and the specific locations of the takes (provide in tabular form if appropriate and a map if available);

c. A description of the method of capture and gear;

d. The holding time required prior to transport or release;

e. A description of the use of drugs, including the purpose of using the drug(s), method of application, kind and combination of drugs and dosage rates (ml/kg), the required holding time, and the names of the personnel who would administer the drugs. In addition, describe the provisions to minimize adverse reaction(s), minimize the chance that drugged animals will escape prior to complete immobilization, and to ensure that the animal is fully recovered prior to release;

f. A description of marking/tagging/instrumentation (MTI), including the type of MTI (including weight and size), the number of MTIs to be applied per animal, the number of animals to be given MTI, methods and location of attachment, whether recapture will be necessary (if so, how many times), whether the MTI has been used previously on this species, the potential adverse effects, the means of monitoring new MTIs for adverse effects, the actions to be taken in the event that the MTI has significant adverse impact on the animal(s), and the method of animal release;

g. A description of minimum approach distance for vessel surveys, aerial surveys, ground surveys, photo-id above the water, underwater divers, focal follows, sampling/biopsy darting, tagging (different distances for each deployment method), and hydroacoustic monitoring and recording;

h. A description of all testing methodologies that will be used on captive held animals, including the equipment to be used, duration and times of testing, and data analyses. Include information about how animals to be released to the wild after testing will be deconditioned from training.

i. Tables of all direct and incidental takes, tagging and sampling activities described above. The tables should include the number of activities that would occur annually; and

j. The anticipated effects of each of the activities alone or cumulatively on the behavior and physiology of the target animals. Describe how the animals will react to your actions and the consequences of those reactions. Identify both short- and long-term potential effects and how you would mitigate those effects.

14. If your activities will or may cause harassment to other marine mammal species or other Federally-protected species, please provide:

a. The number of animals of other marine mammal species that may be harassed, the precautions that will be taken to minimize the likelihood that harassment will occur, and the actions that will be taken should harassment occur.

b. A list of all Federally-protected species which may occur in your project area and may be affected by your activities. Information about these species can be found at http://www.fws.gov/endangered/; and

IMPORT of specimens. For each specimen being imported, provide a response to the following questions.

15. The name of the foreign exporter and the country of export.

16. The proposed date of import.

17. Origin of specimens to be imported and the names of the facilities that currently hold them.

18. The description of the manner in which it was taken from the wild.

19. A copy of the foreign collecting authorization(s).

TRANSPORT of live animals. You must meet USDA standards for Humane and Healthful Transport of Marine Mammals when transporting live animals. If you are transporting animals, respond to each of the following questions.

20. Provide a description of the means and duration of the transportation used to move the specimens, including the proposed dates of transport.

21. Provide a description of the type, size, and construction of all shipping containers used to transport the specimens.

22. Describe the arrangements for watering or otherwise caring for the wildlife during transport.

23. Provide a brief description of the qualifications of each person accompanying the wildlife that demonstrates their ability to address the specimen’s needs during transport.

24. Provide documentation showing compliance with USDA regulations for transport and care of live marine mammals (7 U.S.C. 2131-2159; 9 CFR 3, Part E).

EXPORT of specimens. If you plan to export specimens, provide a response to the following questions. (See Note 2 above: A separate CITES permit will be required prior to the export.)

25. What types of specimens do you plan to export?

26. Provide the complete name and address of person/facility receiving the specimen(s).

27. Describe the origin of the specimens to be exported and the names of the facilities that hold the specimens.

MAINTENANCE of live animals. Answer the following questions for the facility that will be maintaining live animals.

28. Provide a complete description, including photographs and/or diagrams (no blueprints), of the area and facilities where the animals will be held (including the dimensions of pools and haul-out areas), the number of animals of the same species (include age and sex) presently maintained at the facilities, and whether there is space for additional animals without exceeding USDA/APHIS standards (i.e. what is the maximum number of animals of each species that could be held).

29. Provide a list of all animal caretakers and describe their specific duties/responsibilities and a curricula vitae (CV) for each; describe their experience in the care, handling, and maintenance of the marine mammal species that is/are the subject of this application. Include a description of specific State requirements regarding who (e.g., attending veterinarians, vet technicians, researchers) may handle and administer certain drugs.

30. List all marine mammals under the jurisdiction of FWS maintained at the facility.

31. Provide a description of all deaths of FWS marine mammal species at the facility within the past five years and the steps taken to prevent or decrease similar mortalities.

32. Provide a copy of the facility’s U.S. Department of Agriculture (USDA)/Animal and Plant Health Inspection Service (APHIS), Animal Welfare Act (AWA) license and the most recent APHIS inspection report for the applicable marine mammal species.

PUBLIC DISPLAY. Respond to the following questions if the specimens will be on public display.

33. If animal is to be imported, provide:

a. age of animal at time of removal from wild or mother;

b. age at time of weaning; and

c. for females,

(i) at time of removal from the wild: (circle/indicate one) PREGNANT NOT PREGNANT

(ii) at time of proposed import: (circle/indicate one) PREGNANT NOT PREGNANT

34. For U.S. facilities, provide information to show that the facility:

a. is open to the general public without limitations or restrictions (other than by the charging of an admission fee) and

b. offers a program for education or conservation purposes that is based on professionally recognized standards of the public display community (include copies of outreach/educational materials and photos of signage)

SCIENTIFIC RESEARCH. If you are requesting authorization to carry out scientific research, provide a response to each of the following questions.

35. Explain how the research meets the MMPA definition of “bona fide research,” i.e., scientific research on marine mammals, the results of which: (A) is likely to be accepted for publication in a refereed scientific journal; (B) are likely to contribute to the basic knowledge of marine mammal biology or ecology; or (C) are likely to identify, evaluate, or resolve conservation problems.

36. Attach a copy of the formal research proposal or a detailed description of the proposed project, hypotheses, objectives, methods, anticipated results, and disposition of specimen material or animals. Include background information discussing relevant published literature on the subject of your proposal, with citations. Include a power analysis or other sample size estimation to justify your sample size for each gender and age class.

37. Provide the expected research schedule (clearly specify the proposed start date and end date of your research or field season(s) and overall duration of the project). Include the months of the year and frequency of fieldwork/sampling (e.g., how many times per year and how frequently you will sample). If your research extends beyond five years, or is a continuation of previously authorized research, give information about when the research began and when you expect it to end.

38. Provide a list of all personnel that would be involved in the project, identifying each as either principal investigator or co-investigator and the person’s project duties/responsibilities, and provide current curriculum vitae (CV). Include a description of specific State requirements regarding who (e.g., attending veterinarians, vet technicians, researchers) may handle and administer certain drugs.

39. Animal Welfare Act (AWA) Compliance (for research on live animals only): AWA requirements apply to all research facilities, which include institutions, organizations, or people that use or intend to use LIVE animals in research, tests, or experiments; AND, that receive funds under a grant, award, loan, or contract from a department, agency, or instrumentality of the U.S. for the purpose of carrying out research, tests, or experiments, or acquires or transports the animals in commerce.

Please provide the following documentation:

a. Registration under the AWA as a research facility:

i. Attach a copy of your APHIS certificate of registration as a research facility, or for Federal facilities, a letter from your Chief Institutional Officer that you are compliant with applicable requirements for scientific research under the AWA; OR

ii. If your facility does/will not conduct activities requiring registration under the AWA, attach a letter from APHIS confirming that registration is not required.

b. Institutional Animal Care and Use Committee (IACUC) documentation: If your facility is registered as a research facility under the AWA or is a Federal research facility (see a.i), attach the applicable IACUC documentation from the following list (Please note that all activities that involve an invasive procedure, harms, or materially alters the behavior of an animal under study, even if it is carried out in the field, is subject to IACUC review and approval. See AWA regulations and standards for definition/explanation of covered research activities.):

i. Attach a copy of your final protocols with the IACUC signed approval; OR

ii. Attach a copy of your proposed protocols to be reviewed by your IACUC along with an explanation as to how and when the protocols will be reviewed [Note: A copy of your final signed protocols and certification will be required prior to permit issuance.]; OR

iii. Attach the IACUC determination that your research activities are not subject to IACUC review and approval.

c. If your facility is not registered as a research facility under the AWA, please provide an explanation of how your take activities are reviewed and monitored to assure that the proposed takes are humane.

ENHANCEMENT OF SURVIVAL OR RECOVERY. If you are requesting authorization to carry out activities that will enhance the survival or recovery of a species, provide complete responses to the following questions.

40. Provide information to show that your proposed activities are likely to contribute significantly to maintaining or increasing the distribution or population numbers necessary to ensure the survival or recovery of the species or stock in the wild.

41. Provide information to show that your proposed activities are consistent with any conservation plan or recovery plan for the species or stock, or if there are no plans available, that the activity is consistent with the actions required to enhance the survival or recovery of the species or stock that would be addressed in a conservation or recovery plan.

42. For activities that involve captive maintenance of live animals:

1. Provide an explanation on the benefit of removing animals from the wild into captivity; and

2. Include a description of plans in place for returning animals and any offspring to the wild.

FOR ALL APPLICANTS:

43. Provide a copy of any other applicable Federal, local, or state permissions (e.g., National Wildlife Refuge Special Use Permit, NOAA National Marine Sanctuary permit, etc.) required to conduct your proposed work, OR indicate whether you have applied for, secured, or will apply for such permissions (please provide contact information).

44. 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).

45. 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):

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

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

48. 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)]. 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.

PERMIT APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an application for a U.S. Fish and Wildlife Service or CITES permit. 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 blocks/lines/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 application or if applicable on the attached address list.

• Keep a copy of your completed application.

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

• Applications are processed in the order they are received.

• Additional forms and instructions are available from http://permits.fws.gov/ .

COMPLETE EITHER SECTION A OR SECTION B:

Section A. Complete if applying as an individual:

• 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 are not required if not available.

• 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) will not accept doing business as affiliations for individuals.

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

• Enter the complete name of the business, agency, Tribe, 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.

• 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) a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs which use foreign addresses and are not required by DMA.

• Mailing address is address where communications from USFWS should be mailed if different than 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 CFR13.11(d)(3). 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. Fees will not be refunded for applications that are approved, abandoned, or denied. We may return fees for withdrawn applications prior to any significant processing occurring.

• Documentation of fee exempt status is not required for Federal, Tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Those applicants acting on behalf of such agencies must submit 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 current FWS or CITES permit or the number of the most recent permit if none are currently valid. 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 binds the applicant to the statement of certification. This means that you certify that you have read and understand the regulations that apply to the permit. You also certify that everything 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 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 a Take/Import/Transport/Export of Marine Mammals or Amendment of Existing Permit application is 2 hours, 20minutes. 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 <<#>>