Form 3-200-20 Application - Import of Sport-Hunted Trophies (Appendix

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		OMB Control No. 1018-0093 Expires Rev ##/##/####
Return to: U.S. Fish and Wildlife Service Division of Management Authority (DMA) Branch of Permits, MS: IA 5275 Leesburg Pike Falls Church, VA 22041-3803 1-800-358-2104 or 703-358-2104		Type of Activity: IMPORT OF SPORT-HUNTED TROPHIES (Appendix I of CITES and/or ESA)

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details.

See attached instruction pages for information on how to make your application complete and help avoid unnecessary delays.

A.	Complete if applying as an individual
1.a. Last name			1.b. First name	1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)		3. Telephone number	3.a. Alternate telephone number	4. E-mail address

B.	Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution
1.a. Name of business, agency, Tribe, or institution				1.b. Doing business as (dba) 
2. Tax identification no.			3. Description of business, agency, Tribe, or institution
4.a. Principal officer Last name			4.b. Principal officer First name				4.c. Principal officer Middle name/ initial		4.d. Suffix
5. Principal officer title 						6. Primary contact name
7.a. Business telephone number		7.b. Alternate telephone number			7.c. Business fax number			7.d. Business e-mail address

C.		Applicant address All applicants complete address information
1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes) (If Broker or Taxidermist is applying on behalf of a foreign national, provide Broker or Taxidermist’s name and address in this block; U.S. hunters must provide their U.S. address)
1.b. City	1.c. State			1.d. Zip code/Postal code:		1.e. County/Province		1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City	2.c. State		2.d. Zip code/Postal code:		2.e. County/Province		2.f. Country

D.	All applicants MUST complete
1.			Attach check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount of $100, nonrefundable processing fee. Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee – attach documentation of fee exempt status as outlined in instructions. (50 CFR 13.11(d))
2.		Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001. ________________________________________________________________________________________________________________________ Signature of applicant/Principal Officer for permit (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)

Please continue to next page

E. IMPORT OF SPORT-HUNTED TROPHIES (Appendix I of CITES and/or ESA)

Note 1: This form should be used to request authorization to import trophies of species listed on Appendix I of CITES and/or as threatened or endangered under the ESA (examples include elephants, lions, cheetahs, wood bison, and markhor).

PLEASE USE FORM 3-200-19 FOR SOUTHERN AFRICAN LEOPARD TROPHIES AND SOUTHERN WHITE RHINOCEROS TROPHIES TAKEN IN NAMIBIA.

Note 2: If you hold an import permit for trophy/trophies that you did not use, please return the unused original permit. If you are requesting reissuance of a permit because you have taken a trophy, but were unable to import it prior to the expiration of the permit, please use the renewal form (3-200-52) and return your original permit with that form.

Note 3: Applications for species listed as endangered under the U.S. Endangered Species Act are published in the Federal Register for a 30-day public comment period. Please allow at least 90 days for the application to be processed.

Note 4: Sport-hunted trophy is defined at 50 CFR 23.74 as follows: Sport-hunted trophy means a whole dead animal or a readily recognizable part or derivative of an animal specifically identified on the accompanying CITES document that meets the following criteria:

1. Is raw, processed, or manufactured;

2. Was legally obtained by the hunter through hunting for his or her personal use;

3. Is being imported, exported, or re-exported by or on behalf of the hunter as part of the transfer from its country of origin ultimately to the hunter's country of usual residence; and

4. Includes worked, manufactured, or handicraft items made from the sport-hunted animal only when:

   1. Such items are contained in the same shipment as raw or tanned parts of the sport-hunted animal and are for the personal use of the hunter;

   2. The quantity of such items is no more than could reasonably be expected given the number of animals taken by the hunter as shown on the license or other documentation of the authorized hunt accompanying the shipment; and

   3. The accompanying CITES documents (export document and, if appropriate, import permit) contain a complete itemization and description of all items included in the shipment.

Note 5:  Certain hunting trophies, including elephants, are subject to restrictions on their use after import into the United States.  Please see 50 CFR 23.55 for more information or contact the Division of Management Authority.

Please provide the following information. Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you are submitting; please indicate the application question number you are addressing. If applying for more than one trophy, be sure to answer questions 1-5 for each trophy addressed in this application. If importing trophies from more than one country, you must submit a separate application for each shipment in order to obtain separate import permits.

1. Name and address where you wish the permit to be mailed, if different from page 1. If you would like expedited shipping, please enclose a self-addressed, pre-paid, computer-generated, courier service airway bill. If unspecified, all documents will be mailed via regular mail through the U.S. Postal Service.

2. Whom should we contact if we have questions about the application (name, phone number, and e-mail)?

3. Have you or your client (if a broker applying on behalf of your client), been assessed a civil penalty or convicted of any criminal provision of any statute or regulation relating to the activity for which the application is filed; been convicted, or entered a plea of guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird Treaty Act, or the Bald and Golden Eagle Protection Act; forfeited collateral; OR are currently under charges for any violation of the laws mentioned above?

____ No ____ Yes

If you answered “Yes” to Question 3, provide: a) the individual’s name; b) date of charge; c) charge(s); d) location of incident; e) court, and f) action taken for each violation. Please be aware that a “Yes” response does not automatically disqualify you from getting a permit.

4. For each trophy to be imported, provide:

1. Scientific name (genus, species, and, if applicable, subspecies) and common name.

2. Sex (if known).

5. IF ANIMAL IS CURRENTLY LIVING IN THE WILD, Please enter the following information:

a. Country and place (area, region, GIS coordinates, ranch, conservancy, management area, or hunting block, AND nearest city) where wildlife is to be taken from the wild:

b. Date wildlife is to be hunted:

c. Name of hunting outfitter, safari company, or professional hunter you will be hunting with:

6. IF THE TROPHY HAS ALREADY BEEN TAKEN, please enter the following:

a. Country and place (area, region, GIS coordinates, ranch, conservancy, management area, or hunting block, AND nearest city) where trophy was removed from the wild:

b. Date wildlife was hunted:

c. Name of hunting outfitter, safari company, or professional hunter you will be hunting with:

d. The current location of the trophy (address and country) [the U.S. import permit will identify this country as the country of export/re-export and must match with the export/re-export document]:

7. Please provide a copy of any applicable foreign government permits or licenses that were required to remove this animal from the wild (if you have not hunted yet and do not currently hold any such permits or licenses, please indicate so).

8. Complete name and address of overseas person or business shipping the trophy to you. If you are applying to import a trophy directly from Namibia, you must provide the name and address of the professional hunter listed on your Namibian hunting permit [this name will appear on the face of the export permit].

Name:

Business Name:

Address:

City:

State/Province:

Country, Postal Code:

9. For species listed under the Endangered Species Act, please be aware that the U.S. Fish and Wildlife Service must make a finding that your activities will enhance or benefit wild populations of the species involved. While we will communicate with the range country where the species you will hunt/hunted in making the required findings, if you have any information that could support this finding, it would be helpful to our review if you could provide it. Please submit such information on a separate page with your application.

1. Do you have any information regarding the population status or trend data on the species hunted?

2. In order to hunt, you likely paid for licenses or trophy fees. What were those fees and do you have any information on how those funds were used by either the landowner, community, or government?

c. Do you have information on other funding activities that are being carried out, or were carried out, by the safari outfitter, professional hunter, concession holder, or land owner that provide a conservation benefit to the species being hunted/species hunted?

CERTIFICATION STATEMENT (original signature must be provided for either 10 or 11 below)

10. If you are a broker or taxidermist applying on behalf of a U.S. hunter or foreign national, provide documentation to show you have a Power of Attorney to act on your client’s behalf and sign the following statement.

I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted by my client and is being imported only for my client's personal use (i.e., not for sale, transfer, donation, or exchange that is reasonably likely to result in economic use, gain, or benefit). I understand that my client may only import two leopard trophies and two elephant trophies within the same calendar year (if applicable). In addition, I have advised my client that raw ivory, once imported into the United States, cannot be re-exported.

Taxidermist/Broker’s signature: ____________________________________ Date: ______________

11. If you are the hunter applying to import your own trophy, please read and sign the following statement.

I acknowledge that the sport-hunted trophy/trophies to be imported has been/will be personally hunted by me and is being imported only for my personal use (i.e., not for sale, transfer, donation, or exchange that is reasonably likely to result in economic use, gain, or benefit). I understand that I may only import two leopard trophies and two elephant trophies within the same calendar year. In addition, I understand that raw ivory, once imported into the United States, cannot be re-exported.

Applicant's signature: ____________________________________________ Date: ___________

Be aware that there may be additional permitting or approval requirements by your local or state governments, as well as required by other Federal agencies or foreign government to conduct your propose activity. While the Service will attempt to assist where possible, it is your responsibility to obtain such approval.

12. All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. If you wish to use a port not listed, please contact the Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).

APPLICATION FORM INSTRUCTIONS

The following instructions pertain to an U.S. Fish and Wildlife Service (FWS) permit applications. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates are referred to as a permit.

GENERAL INSTRUCTIONS:

• Complete all relevant questions in Sections A or B, C, D, and E.

• An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate application form for the proposed activity.

• Print clearly or type in the information. Illegible applications may cause delays.

• Sign the application. Faxes or copies of the original signature will not be accepted.

• Mail the original application to the address at the top of page one of the application or, if applicable, on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 60 days for your application to be processed, however, some applications may take longer than 90 days to process (50 CFR 13.11).

• Applications are processed in the order they are received.

SECTION A OR SECTION B:

Section A. Complete if applying as an individual [do not complete this section if applying for Import/Export License (3-200-3)]:

• Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the applicant. Fax and e-mail, while helpful in processing, are not required.

• If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be included with the application.

• Affiliation/ Doing business as (dba): business, agency, Tribe, organizational, or institutional affiliation directly related to the activity requested in the application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division of Management Authority (DMA) and the Office of Law Enforcement (OLE) do not accept doing business as affiliations for individuals (complete Section B)..

Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:

• Enter the complete name of the business, agency, or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the applicant is engaged in. Provide contact phone number(s) of the business. If you are applying on behalf of a client, a document evidencing power of attorney must be included with the application.

• Principal Officer is the person in charge of the listed business, corporation, public agency, Tribe, or institution. The principal officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at the business, corporation, public agency, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted to the Division of Management Authority (DMA), a physical U.S. address is required.

• Mailing address is the address to which communications from USFWS should be mailed if different from applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is required at the time of application, unless exempted under 50 CFR13. The application processing fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit, nor will fees be refunded for applications for which processing has begun.

• Documentation of fee exempt status is not required for applications submitted by Federal, Tribal, State, or local government agencies; but must be supplied by those applicants acting on behalf of such agencies. Such applications must include a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most recent issued USFWS permit. If applying for re-issuance of a CITES permit, the original permit must be returned with this application.

Section D.3 CERTIFICATION:

• The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation must be included in the application) must sign and date the application. This signature legally binds the applicant to the statement of certification. You are certifying that you have read and understand the regulations that apply to the permit. You are also certifying that all information included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

ALL APPLICANTS COMPLETE SECTION E

Please continue to next page. DO NOT RETURN THIS PAGE WITH THE APPLICATION

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:

1. The gathering of information on fish and wildlife is authorized by:

(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.html

a. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;

b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50 CFR 17;

c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;

d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;

e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;

f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;

g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/ , 50 CFR 23;

h. General Provisions, 50 CFR 10;

i. General Permit Procedures, 50 CFR 13; and

j. Wildlife Provisions (Import/export/transport), 50 CFR 14.

2. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. We may not conduct or sponsor and you are not required to respond to collection of information unless it displays a currently valid OMB control number.

3. Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972 (16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4. Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)

a. Routine disclosure to subject matter experts, and Federal, Tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a FWS function related to this system of records.

b. Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the decision on a permit application.

c. Routine disclosure to Federal, Tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all applicable permitting requirements.

d. Routine disclosure to Captive‑bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive breeding of these species.

e. Routine disclosure to Federal, Tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.

f. Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or administrative body, under certain circumstances.

g. Routine disclosure to the appropriate Federal, Tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or regulated use.

h. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.

i. Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.

j. Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by the FWS.

5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application.

6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for an Import Of Sport-Hunted Trophies (Appendix I of CITES and/or ESA) application is 1 hour. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803.

Freedom of Information Act – Notice

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].

DO NOT RETURN THIS PAGE WITH THE APPLICATION

Form 3-200-20 Rev. 04/2017 Page 6 of 6