Form 3-2378 Federal Subsistence Designated Fishing Application

OMB Control No. 1018-0075
Expires: XX/XX/XXXX

Federal Subsistence Designated Fishing Application
Year:

Season:

Applicant's Name (First, Middle Initial, Last)

Date of Birth

Permit #

Mailing Address

Physical Address

City, State, Zip Code

Community of Primary Residence

AK Drivers License # or other acceptable ID Telephone Number(s)

Applicant's Signature

Date Permit Issued (mm/dd/yy)

Issuing Agent (Print)

X
I certify that I am a rural resident as defined by 50 CFR 100.4 and 36 CFR 242.4. I have read and
understand the conditions on the permit and agree to comply with them and
applicable regulations as found in 50 CFR 100 and 36 CFR 242.

Federal Subsistence Designated Fishing Report
List All Other Persons for Whom You Fished:
Name

Permit #

Species

Check here if you did not fish
Number
Retained

Gear

Report Due by:
Other

**** Attach Additional sheets if necessary ****
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. This information collection is authorized by the Alaska National Interest
Lands Conservation Act and associated regulations. The Federal Subsistence Board will use this information to manage fish and wildlife resources for subsistence uses. It is our policy not to use your name for any other
purpose. We will maintain this information in accordance with the Privacy Act. Your response is voluntary, but is required to obtain or retain a benefit. We may not conduct or sponsor and you are not required to respond to an information collection unless it displays a currently valid OMB control number. OMB has approved this information collection and assigned OMB Control No. 1018-0075. We estimate it will take you about
15 minutes to complete the application and record your harvest. This burden estimate includes time for reviewing instructions, gathering 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 Collection Clearance Officer, Fish and Wildlife Service, Mail Stop 2042-PDM, Arlington Square, Department of the Interior, 1849
C Street, NW., Washington D.C. 20240.
FWS Form 3-2378
10/09

Permit Conditions:

Fold on this line (second) - After making the folds, tape this flap to the bottom of the letter, making sure that the return address is visible.

Fold on this line (first)

Return Address

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

BUSINESS REPLY MAIL

FIRST CLASS MAIL

PERMIT NO. 12874

ANCHORAGE AK

POSTAGE WILL BE PAID BY ADDRESSEE

Address

Post Office Bar Code