Form 3-200-46 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: Import/Export/Re-export of Personal Pets (CITES and/or Wild Bird Conservation Act)

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 of $50, 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)

Please continue to next page

5. IMPORT/EXPORT/REEXPORT OF PERSONAL PETS (CITES and/or Wild Bird Conservation Act)

Note: this form is for the one-time import, export, or re-export of pets. If you are a U.S. resident and intend to travel with your pet in and out of the United States several times over the next few years, use form 3-200-64 (www.fws.gov/forms) to apply for a U.S. CITES Certificate of Ownership. This form may also be used by non-U.S. residents, with pet birds intending to travel to the United States under a foreign CITES Certificate of Ownership, applying for a matching 3-year WBCA permit.

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 applying for more than one animal there must be documentation for each animal. Be sure to indicate which animal is being addressed in each response.

1. Are you requesting authorization to:

___ IMPORT your pets into the United States? (Only two (2) birds allowed per person for import).

___ EXPORT your pet from the United States?

___ RE-EXPORT your pet from the United States (see question 9)?

2. What is your expected date of import/export: _______________________________________

(Note: please allow at least 30 days, preferably 60 days, for the processing of this application.)

3. Provide your foreign address, including country (if U.S. address is not indicated on page 1, provide U.S. address):

Name:

Street Address:

City:

State/Province

Country, Postal Code:

4. For EACH pet to be imported or exported provide the following: If needed, use a separate sheet of paper.

Scientific name (genus, species, and, if applicable, subspecies)	Common Name	Hatch date mm/dd/yyyy	Sex	Permanent marking1 and/or name	Source (wild/ captive-born)	Country where the animal was acquired

5. What is the current location of your pet(s)?

______________________________________________________________________________

ORIGIN OF YOUR PET: answer question 6 if your pet was wild-caught; question 7 if your pet was captive-born; and question 8 if you do not know the origin of your pet.

6. For animals that were wild caught:

a. If your pet was removed from the wild within the United States, provide:

i. Evidence that it was legally acquired (State authorization);

ii. The purpose for which the bird was removed from the wild; and

iii. The date the bird was removed from the wild.

iv. Documentation demonstrating the history of transactions (e.g., chain of ownership of pet(s)).

b. If your pet was removed from the wild outside the United States, provide:

i. Country of origin;

ii. Evidence that it was legally imported into the U.S. (you may refer to question 9);

iii. The purpose for which the bird was removed from the wild;

iv. The date the bird was removed from the wild; and

v. The date you acquired the bird.

vi. Documentation demonstrating the history of transactions (e.g., chain of ownership of pet(s)).

7. For animals that were captive-born:

a. If you are the breeder, provide a signed statement that the animal was bred and born at your facility. This statement must include the following:

i. Scientific and common names of bird;

ii. Hatch date, band/tag number, and sex of each bird;

iii. Name and address of your facility where the bird was bred and born;

iv. Location of parental stock; and

v. Your signature and date.

vi. Documentation demonstrating the history of transactions (e.g., chain or ownership of pet(s)).

b. If you are NOT the breeder of the animal, provide a signed statement from the breeder or breeder's record that includes the following:

i. Scientific and common names of bird;

ii. A statement that the bird was bred and born at his/her facility;

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

iv. Location of parental stock;

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

vi. Copies of documentation showing that you acquired the bird from the breeder or documentation demonstrating the history of transactions (e.g., chain of ownership of your pet(s)).

8. If you do not know the origin of your pet, provide a signed and dated statement with a complete description of the circumstances under which you acquired the pet, including when, where, from whom, and any other pertinent information. Include pet store receipts or other information that would assist in determining the source of your pet.

9. For the EXPORT of an APPENDIX-I bird², provide a copy of the foreign CITES import permit or evidence that one will be issued.

10. For RE-EXPORT (bird was previously imported into the United States), provide evidence that the bird was legally imported, including:

a. Copies of canceled CITES export permits or re-export certificates issued by the appropriate CITES office in the country from which the bird was imported, and a copy of the cleared Declaration for Importation (Form 3-177).

b. If you did not make the original import, provide copies of the importer’s documents outlined above and any invoice or other documents that show you purchased or otherwise obtained the bird from the original importer. If you did not obtain the wildlife from the original importer, include documentation demonstrating the history of transactions.

c. For birds previously imported, provide a copy of your Wild Bird Conservation Act (WBCA) import authorization (non-native birds) or Migratory Bird Treaty Act authorization (native birds).

11. For pet(s) that are PRE-CONVENTION (i.e., the bird was born before the species was listed under CITES), provide documents, signed statements, or other evidence that the bird was obtained prior to the date CITES applied to it (i.e., bill of sale, signed breeder’s records, or signed affidavit attesting to age of bird).

12. FOR IMPORT OF BIRDS ONLY:

a. Provide documentation that shows you have continually resided outside of the United States for at least one (1) year just prior to submission of this application. (e.g., employment records, utility bills).

b. Provide your primary addresses where you resided for the last full year consecutively.

__________________________________________ From _________To_______

__________________________________________ From _________To_______

__________________________________________ From _________To_______

c. Have you imported any non-native birds in the last 12 months? Yes___ No _____

If yes, how many? ____________

13. If you are applying for a three-year WBCA import permit (i.e., you are a non-US resident traveling through the United States), you must provide a copy of your valid foreign CITES Certificate of Ownership (Pet Passport).

14. For the export of a migratory bird (listed in 50 CFR 10.13), provide Federal and State permit or license numbers that authorize possession and acquisition, where such document is required.

15. Please provide a description of the shipping conditions:

Your description must include:

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

b. The arrangements for watering or otherwise caring for your pet during transport.

The transport conditions 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).

15. CERTIFICATION STATEMENT (All applicants must complete with an original signature)

I understand that the purpose for the bird(s) identified in this application is to import, export, or re-export my personally owned pet(s) and I have no intention of selling the bird(s) or using the bird(s) for any commercial activity.

Applicant’s signature: _______________________________________ Date: _________________

17. Be aware that certain States require pet possession certificates. Contact your State conservation agency (http://www.fws.gov/offices/statelinks.html) for pertinent requirements, and submit copies of applicable documentation with your application.

18. All international shipment(s) of wildlife must be declared to the U.S. Fish and Wildlife Service at the time of export/import. A list of designated ports (where a wildlife inspector is posted) is available from http://www.fws.gov/le/designated-portshtml. If you wish to use a port not listed, additional authorization to use a non-designated port will be required. If you wish to use several different non-designated ports, you may be required to contact the Office of Law Enforcement for additional authorization.

Enter the U.S. port(s) through which the [export/re-export/import] is anticipated to occur: _____________________________________________________________.

19. 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):

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

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

22. 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.

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 60 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://www.fws.gov/forms/display.cfm?number1=200

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 an Import/Export of Personal Pets application is 30 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 (e.g., tattoo number; band number; microchip number, type, and location on animal; prominent scars)

2 If you are not sure which Appendices your pet is listed under, contact the Division of Management Authority at 800/358-2104.

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