Observer/catch provider permits and appeals

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/

INSTRUCTIONS
This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address
given above to apply for a provider permit. The provider permit authorizes an entity to provide observer and/or
catch monitors to participants in the Pacific Coast Groundfish fishery. The permit is effective upon approval by
NMFS and expires December 31st. You may apply for a provider permit at any time, however if you want the
permit to be effective on January 1 of the following year, you must submit your permit application no later than
October 31st.
Section A – Provider Information
The applicant must provide their legal name as registered in a U.S. state, tax identification number and indicate
the state they are registered in. Also, the applicant must provide their business mailing address, business
phone number and, optionally, fax number and email address.
Section B –Endorsements
The applicant must indicate whether they are requesting an observer endorsement or catch monitor
endorsement or both. If the applicant requests one endorsement and at a later time wishes to obtain the second
endorsement, a separate application must be completed and submitted to NMFS.
Section C – List of Current Owners, Board Members, Officers, Authorized Agents and Employees
Please provide the name and date of birth of the all current owners, board members, officers, authorized agents
and employees of the applicant organization. Also, identify the role(s) of each individual using the abbreviations
associated with each role. The term “employee” does not include observers or catch monitors but rather
individuals who work in support of applicant entity and carryout administration and activities in support of the
provider (e.g.; recruiting, hiring, deployment, accounting, database management). Similarly, the term
“authorized agent” refers to an individual authorized by the applicant owners or management to carry out certain
legally binding business activities.
Section D – Description of Management and Organization Structure
Describe the management and organizational structure of the applicant entity. This narrative should provide,
but is not limited to, a general description of the general operational units of the organization, the staff assigned
to such units and their title/responsibilities and the supervisory structure of the organization. Also, list all office
locations including the business addresses, phone numbers, and optionally fax numbers, email addresses the
name of a contact at each location. If the applicant is a corporation, please provide a copy of the articles of
incorporation and if the applicant is a partnership, the partnership agreement. You may want to include an
organizational chart in this section or append to the application.

Section E – Applicant Prior Experience and Qualifications
For each of the endorsements you are applying for, please describe any prior relevant experience or
qualifications the applicant may have that would qualify them for this permit and endorsement. 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, expertise or educational backgrounds of owners and employees.
Section F – Description of Ability to Carry out Required Responsibilities/Duties
For each of the endorsements you are applying for, please describe your ability to carry out the required
responsibilities and duties listed for observer and/or catch monitor providers as described in regulation. You
may use the space provided below to describe experience/qualification or attach to the application a written
narrative. For an observer endorsement please refer to the following regulations to see the specific
responsibilities and duties: observers on vessels in the shorebased fishery: 50 CFR 660.140(h); mothership
fishery: 50 CFR 660.150(j) and catcher processor fishery: at 50 CFR 660.160(g). For catch monitor
endorsement please refer to the regulations at 50 CFR 660.17(e). Please note that the requirements for
observers for various fisheries and catch monitors may be unique and need to be specifically addressed in your
application.
Section G – Conflict of Interest, Criminal Convictions, Performance Ratings on Federal Contracts and
Decertification
In this section, the authorized representative who will certify the application in Section G, must under penalty of
perjury, either affirm OR not affirm that all current owners, board members, officers, authorized agents and
employees are free from conflict of interest as defined in 50 CFR 660.18(c)(3), criminal convictions, an
unsatisfactory performance rating on a Federal contract, and a previous decertification action while working as
an observer, catch monitor, observer provider, or catch monitor provider. If the authorized representative
specifies “Do Not Affirm” for any of the above or is unsure, the applicant must provide a written statement
providing relevant information describing why you cannot affirm for any of the four items given.
Section H – Certification of Applicant and Notary
The applicant’s authorized representative must sign and date this form in the presence of a notary to certify that
the individual signing the form has been satisfactorily identified. By signing and dating the form, the authorized
representative acknowledges they are authorized to make the certification on behalf of the provider, and
certifies that all information set forth in the application (both in the form and appended to the form) is true,
correct and complete to the best of their knowledge and belief. The authorized representative must print their
name. The form must be signed, dated and notarized to be considered complete.
Supplemental Documentation
Please provide any additional information or documents you feel may support your request for a provider
permit and endorsement(s).