Pacific Coast Groundfish Mothership Cooperative Permit A

OMB Control No. 0648-0620, Expires on: 11/30/2014

Mothership Cooperative Permit Application Form Pacific Coast Groundfish Trawl Rationalization Program

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

INSTRUCTIONS

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to apply for a mothership (MS) cooperative permit. To be an eligible MS cooperative (coop) entity, a group of mothership catcher vessel (MS/CV) endorsed limited entry permit owners (coop members) must be a recognized entity under the laws of the United States or the laws of a State and represent all of the coop members. The coop must include at least 20 percent of all MS/CV-endorsed permits as members. This application must be postmarked no later than March 31 of the year in which the coop intends to fish. An MS cooperative permit is effective upon approval by NMFS.

Section A – Cooperative Contact Information

Please provide the cooperative entity name, tax identification number (TIN), and state that the entity is registered in, as well as the business mailing address, phone number, fax number, and email address. Also provide the name of the cooperative manager and their date of birth (DOB).

Section B – Mothership Catcher Vessel Permits Obligated to Cooperative and Processor Obligation

The applicant must provide the permit number for each coop member’s MS/CV-endorsed limited entry permit, the MS/CV endorsement and catch history assignment (CHA) ID number, and the associated CHA amount (expressed as a percentage) as given on the permit. Also indicate the MS permit that each MS/CV-endorsed limited entry permit is obligated to. Please note that if one MS/CV-endorsed limited entry permit has multiple MS/CV-CHAs, you will need to list and obligate each separately. Please indicate the total whiting catch history allocation that will accrue to the coop based on the sum of the individual MS/CV permits obligated to the coop. If Section B does not provide sufficient space to list all permits, copy this section, add the additional information and append to the application.

Section C – Catcher Vessel Information

Please provide the vessel name and USCG vessel documentation number for each catcher vessel fishing for the coop. If Section C does not provide sufficient space to list all catcher vessels, copy this section, add the additional information and append to the application.

Section D – Certification of Applicant and Notary

The applicant or authorized representative must sign and date the form in the presence of a notary to certify that the individual(s) signing the form has satisfactorily identified themselves. By signing and dating the form, the applicant or authorized representative certifies that all information set forth in the form is true, correct and complete to the best of the applicant’s knowledge or belief. The form will not be considered without the authorized representative’s signature. NMFS may request that the authorized representative for a business entity include a copy of the corporate resolution or other document authorizing the individual to sign and certify on behalf of the business entity. The notary must sign and date this section, and affix a notary stamp or seal.

Supplemental Documentation

The applicant must provide a copy of the cooperative agreement and any inter-coop agreement entered into at the time of the application submission, consistent with the regulations given at 50 CFR 660.150.

OMB Control No. 0648-0620, Expires on: 11/30/2014

Mothership Cooperative Permit Application Form Pacific Coast Groundfish Trawl Rationalization Program

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, Northwest Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

Section A – Cooperative Contact Information
1. Name of Cooperative Entity			2. Cooperative TIN
			3. State Cooperative Entity Registered In
4. Business Mailing Address Street or PO Box			5. Business Phone Number ( )
			6. Business Fax Number (optional) ( )
City	State	Zip Code	7. Business Email (optional)
8. Name of Cooperative Manager			9. Cooperative Manager DOB

Section B – MS/CV Permits Obligated to Cooperative and Processor Obligation
MS/CV-Endorsed Permit Number	MS/CV Endorsement and CHA ID Number	Catch History Assignment	Obligated to MS Permit Number
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
GF		%	MS
Total This Page		%
Total From Other Pages		%
Total Coop Whiting Allocation (sum of all MS/CV-endorsed permit whiting catch history assignments)		%

Section C – Catcher Vessel Information
Vessel Name	USCG Vessel Documentation Number

Section D – Certification of Applicant and Notary This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative
Notary Public Signature  ATTEST	Affix Notary Stamp or Seal Here
Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.

PRIVACY ACT STATEMENT: Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. TIN, DOB, business phone number, fax number, email and contents of the cooperative agreement are not released to the public. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 4.00 hours per response (with coop agreement), including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other suggestions for reducing this burden to NOAA/National Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

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