Form 3-2273 Title 50 Certifying Official Form

Form 3-2273 (Rev. 02/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

Title 50 Certifying Official Form

(for use by new applicants and those seeking recertification)

Name & Professional Degrees: _______________________
Position Title: ----------------------------Current Place of Employment:---'---------------------­
Address:

Work Phone: ____________________________
FAX & Email Address: ------------------------Primary Duties:

Areas of Expertise & Related Certifications:

Facilities Available for Diagnostic Tests:

Form 3-2273 (Rev. 02/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

Available Equipment:

Signature: ______________________________________________ Date: _________________
Return to:

U.S. Fish and Wildlife Service
Division of the National Fish Hatchery System
5275 Leesburg Pike
Falls Church, VA 22041
USA
Attn: Title 50 Certification Form
(If more space is required to adequately answer questions, please use an extra sheet.)
NOTICE

In accordance with the Paperwork Reduction Act (44 U.S.C 3501), please be advised that:
1. The gathering of information is authorized by the Lacey Act (18 U.S.C. 42) and Title 50, Part
16, of the Code of Federal Regulations.
2. Failure to provide all of the requested information is sufficient cause for the U.S. Fish and
Wildlife Service to deny your request for certification as a Title 50 inspector under Title 50,
Part 16, of the Code of Federal Regulations.
3. You are not required to respond to a collection of information unless it displays a currently
valid OMB Control Number.
4. This information collection has been approved by OMB and assigned Control Number
1018-0078.
5. The requested information may be subject to disclosure under provisions of the Freedom of
Information Act 95 U.S.C. 552).
The public reporting burden for the information collected on this form is 60 minutes. This burden
estimate includes time for reviewing instructions, gathering data, and completing and reviewing
the form. Comments on this form should be directed to the Information Collection Clearance
Officer, Division of Policy, Performance, and Management Programs, U.S. Fish and Wildlife
Service, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803.