Sample Customized Form

OMB Control No. 1018-0153

Self-Clearing Check-In Permit

Expires XX/XX/XXXX

You must complete the Check-In portion of this daily permit and put it in
the permit box before engaging in any activity on the Refuge.

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U. S. Fish and Wildlife Service
(Refuge will insert refuge name)
Each user must [carry/display on dash] the Daily Visitor Registration portion
while on the Refuge. At the conclusion of your visit, complete the following
information and put this portion in the permit box.
Number of hours spent on Refuge
Hunter Harvest Information: (Please check all that apply)
(Option 1:) Did you harvest any wildlife?
How many ? - Example: Squirrel 3

Yes

No

(Option 2:) What were you hunting ? How many did you harvest ?
(Check all that apply)
(Put Zero if no game harvested)
Example: X Squirrel _3_ X Deer _0_
Game Species
(Each Refuge will list relevant species with a space for the number harvested
and other relevant data required.)
Incidental Species
(Each Refuge will list relevant incidental species and other relevant data
required.)
Method:
(Each Refuge will list allowable methods of harvest.)
Angler Harvest information:
(Each Refuge will list relevant species and other relevant data required.)
Did you observe:
(Each Refuge will list relevant species.)
--- Notice --In accordance with the Privacy Act (5 U.S.C. 552a) and the Paperwork Reduction Act
(44 U.S.C. 3501), please note the following information: 1. The issuance of a permit and
collection of fees on lands of the National Wildlife Refuge System is authorized by the
National Wildlife Refuge System Administration Act (16 U.S. C. 668dd-ee) as
amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4). 2. This information
is required in order to obtain or retain a benefit. It is our policy not to use your name for
any other purpose. The information is maintained in accordance with the Privacy Act
System of Records: National Wildlife Refuge Special Use Permits--Interior, FWS-5).
False, fictitious, or fraudulent statements or representations made in the application may
be grounds for revocation of the permit and maybe punishable by fine or imprisonment
(18 U.S.C.1001). Failure to provide all required information is sufficient cause for the
U.S. Fish and Wildlife Service to deny a permit. 3. We estimate the public reporting
burden for information collection to be 5 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,
BPHC, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240. 4.
Routine use disclosures may be made: (a) to the U.S. Department of Justice when
related to litigation or anticipated litigation; (b) of information indicating a violation or
potential violation of a statute, rule, order, or license to appropriate Federal, State, local
or foreign agencies responsible for investigating or prosecuting the violation or for
enforcing or implementing the statute, rule, regulations, order, or license; (c) from the
record of the individual in response to an inquiry from a Congressional office made at
the request of the individual (42 FR 19083; April 11, 1977); and (d) 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 Department (48 FR 54716; December 6, 1983). 5. An agency may not conduct or
sponsor and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number.

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Self-Clearing Daily Vehicle Permit
Each user must enter the date and, while on the Refuge,
display this tag in the vehicle in clear view.

VEHICLE TAG
Other Side Face-up
FWS Form 3-2405
REV 10/15

Self-Clearing Check-In Permit
U. S. Fish and Wildlife Service
(Refuge will insert refuge name here)
Daily Permit Check in Date:
Name:
Ph#:

(pre-coded) Permit #
Cel#:

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Self-Clearing Daily Visitor Registration Permit
Each user must complete the following information and
[carry this portion/display on dash] while on the Refuge.
At the conclusion of your visit, complete the information
on the reverse side and put this portion in the permit box.
Date

(pre-coded) Permit

#

Name
City

State

Zip Code
Purpose of Visit: (Please check all that apply)
Hunting
Photography

Birding

Wildlife Observation

Auto Touring

Boating/Canoeing

Fishing

Visitor Center

Environmental Education Class

Hiking
Special Event

Volunteering

Other Recreation (please specify):

_

Refuge Unit(s) Visited
Map of Refuge or Refuge Unit(s)

(Refuge will insert a map of the refuge)

Comments:

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Self-Clearing Daily Vehicle Permit
Date:

_ (pre-coded) Permit #

If there is more than one person in the vehicle,
there must be a tag for each user displayed
in the vehicle in clear view.

_