Form 3-2275 Title 50 Importation Request Form

Form 3-2274 (Rev. 02/2017)
U.S. Fish and Wildlife Service

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

Title 50 Importation Request Form
(Approvals will only be granted upon receipt of a valid Title 50
Health Certification and after consultations with the State resource
agency of the state receiving the eggs or animals)

Company/Agency Receiving Animals or Eggs: _____________
Name of Facility to Receive Animals or Eggs:---==============­
Add ress of Facility: �===================�---___:.

Import Request:
Number:

Life Stage:

Species:

Number:

Life Stage:

Species:

Number:

Life Stage:

Species:

Number:

Life Stage:

Species:

Number:

Life Stage:

Species:

Number:

Life Stage:

Species:

Origin of Eggs or Fish:
Name and Addn:ss of Exporter

Signature: ____________

Date:--------------

Name:

Title:

Address: -----------City/State/Zip: _____________.
Phone: "----

-----------------

Fax:

Please Return To:
U.S. Fish and Wildlife Service
Division of the National Fish Hatchery System
5275 Leesburg Pike
Falls Church, VA 22041
USA

Form 3-2274 (Rev. 02/2017)
U.S. Fish and Wildlife Service

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

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 to import salmonids or their eggs 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 0MB control number.
4. This information collection has been approved by 0MB and assigned clearance number
1018-0078.
5. The requested information may be subject to disclosure under provisions of the Freedom of
Information Act (5 U.S.C. 552).
The public reporting burden for the information collected on this form is 15 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.