Observer/catch monitor provider permit application

OMB Control No. 0648-0619; Expires: 04/30/2018

OBSERVER/CATCH MONITOR
PROVIDER PERMIT
APPLICATION FORM
PACIFIC COAST GROUNDFISH
FISHERY

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

Section A – Applicant Information
1. Legal Name of Applicant

2. TIN (if business) or DOB (if person)

3. State Registered In (if business)

4. Business Mailing Address

5. Business Phone Number

(

Street or PO Box

)

6. Business Fax Number (optional)

(
City

State

Zip Code

)

7. Business Email (optional)

Section B – Endorsement Request
[Check one or both]

Observer Endorsement

Catch Monitor Endorsement

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Section C – List of Owners, Board Members, Officers, Authorized Agents and Employees

List Names of All Current Owners, Board Members, Officers, Authorized Agents and Employees
Name

Date of Birth

Role in Applicant Organization
O = Owner; BM = Board Member; OF = Officer
AA=Authorized Agent and E = Employee

If you need to list additional persons, please make a copy of this page and type “Continued” at top and append to
application.

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Section D – Description of Management and Organizational Structure

Please describe the management and structure of the applicant organization. At a minimum, such
description should provide the general functional responsibilities of various staff, all office locations
and their business addresses, business phone number, fax number and email addresses. Also, if a
corporation attach articles of incorporation or if a partnership, attach the partnership agreement.

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Section E – Applicant Prior Experience and Qualifications
For the endorsement(s) you are applying for, please describe any prior relevant experience or
qualifications the applicant may have that would qualify them for this provider permit/endorsement(s).
Prior relevant experience includes but is not limited to: recruiting, hiring, deployment, personnel
administration and placing/supporting individuals in remote field or marine work environments.
Qualification elements may include the knowledge or educational background of owners and
employees.
Observer Endorsement:

Catch Monitor Endorsement:

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Section F – Description of Ability to Carry out Required Responsibilities/Duties
For the endorsement(s) you are applying for, please describe your ability to carry out the required
provider responsibilities and duties listed for observers and/or catch monitors as described in
regulation. You may use the space provided below to describe experience/qualification or attach to
the application a written narrative.
Observer Endorsement: (see responsibilities/duties described for observers on vessels in the
shorebased fishery: at 50 CFR 660.140(h); mothership fishery at 50 CFR 660.150(j) and catcher
processor fishery at 50 CFR 660.160(g).)

Catch Monitor Endorsement: (responsibilities/duties given at 50 CFR 660.17(e))

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Section G – Conflict of Interest, Criminal Convictions, Negative Performance Ratings on Federal
Contracts, and Decertification
Under penalty of perjury, I either Affirm or Do Not Affirm as specified below, that all owners, board
members, officers, authorized agents, and employees, are free from the following:

Affirm

Do Not Affirm

Conflict of interest as described in 50 CFR § 660.18 (c)(3)
Affirm

Do Not Affirm

Criminal convictions
Affirm

Do Not Affirm

Affirm

Do Not Affirm

Any previous Federal contract with an unsatisfactory
performance rating
Any previous decertification action while working as an
observer, catch monitor, observer provider, or catch monitor
provider

Please Note: If you cannot affirm any of these statements or are unsure, check “Do Not Affirm” and
attach to the application relevant information to enable NMFS to make a decision.

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Section H – 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.
Date

Signature of Authorized Representative

Printed Name of Authorized Representative

Affix Notary Stamp or Seal Here

Notary Public Signature

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: All of the information collection described above is confidential under section 402(b) of the MagnusonStevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics except for the name and
address of the applicant and the endorsement requested. 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 10 hours per response, 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, West Coast 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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