3-177a Declaration For Importation Or Exportation Of Fish Or Wi

USFWS Form 3-177
(Revised 03/10)
O.M.B. No. 1018-0012
Expiration Date: 04/30/2016

2. Import/Export License Number:

Page ____ of _____

U.S. FISH AND WILDLIFE SERVICE
DECLARATION FOR IMPORTATION
OR EXPORTATION OF
FISH OR WILDLIFE

13. Name of U.S. Importer or Exporter:
8. Air Waybill or Bill of Lading Number:
Master:

CONTINUATION SHEET
House:
Species
Code

(Official Use
Only)

16a. Scientific Name

17a. Foreign CITES Permit Number

16b. Common Name

17b. U.S. CITES
Permit Number

18a. Description
Code

19a.
Quantity /Unit

18b. Source
Code

19b. Total
Monetary Value

20.
Country of
Species
Origin
(ISO Code)

21.
Venomous
Live Wildlife
Indicator ;
(Check if yes)

†
†
†
†
†
†
†
†
†
Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or
Wildlife may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C.
3372(d).

22. I certify under penalty of perjury that the information furnished is true
and correct:
______________________________________________ ____________
Signature

Date

For Official Use Only

____________________________________________________________
Type or Print Name

See Reverse Side of this Form for Privacy Act Notice