Form 3-200-23 Application - Export of Pre-Convention, Pre-Act, or Anti

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		OMB Control No. 1018-0093 Expires ##/##/####
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: Export or Re-Export of Pre-Convention, Pre-Act, or Antique Specimens (CITES, MMPA 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)
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 $75, 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. EXPORT or RE-EXPORT OF PRE-CONVENTION, PRE-ACT, OR ANTIQUE SPECIMENS (CITES, MMPA or ESA)

Description	Applicable Date
pre-Convention (CITES)	Specimen was acquired (removed from the wild or born or propagated in a controlled environment) before the date CITES applied to it. The CITES listing date can be found at http://www.cites.org.
pre-Act (ESA)	Specimen was held in a controlled environment on or before (a) December 28, 1973 or the date when the species was listed under the ESA, and (b) the holding or use was not in the course of a commercial activity (e.g., it has not been bought, sold, or offered for sale by you or anyone else) since December 28, 1973, or the date when listed under the ESA.
Antique (ESA)	Specimen is not less than 100 years old ago, has not been repaired or modified on or after December 28, 1973 with any part of any species protected by ESA and a) has entered at a port1 designated for the import of ESA antiques or b) there is documented proof that the specimen was in the United States prior to September 22, 1982.
pre-MMPA	Specimen was taken prior to December 21, 1972.

CITES - Convention on International Trade in Endangered Species of Wild Fauna and Flora

MMPA – Marine Mammal Protection Act

Act or ESA – Endangered Species Act

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 submit, indicate the application question number you are addressing.

Note 1: For shipment of Brazilian rosewood (Dalbergia nigra), submit form 3-200-32

(http://www.fws.gov/international/permits/by-form-number/index.html)).

Note 2: Finished products of some timber species, such as big leaf mahogany, are not covered under CITES (only logs, sawn timber, and veneer), while other finished products of species, such as Dalbergia latifolia (Indian rosewood) require CITES documents. If you want to export furniture or other finished products containing CITES-listed wood, please contact the Division of Management Authority to determine if a CITES document is required.

Note 3: For fossilized walrus ivory removed from the wild after 1972, please use form 3-200-27 (http://www.fws.gov/international/permits/by-form-number/index.html)

Note 4: African elephant ivory: Raw ivory cannot be re-exported. Worked ivory that qualifies as an antique may be exported. For non-commercial exports, antique worked ivory may also be exported. In addition, worked ivory that was removed from the wild before February 4, 1976, and is part of either a household move or an inheritance could qualify to be exported. (For export of worked African elephant ivory that is contained in a musical instrument, please use form 3-200-88; for worked African elephant ivory that is part of a traveling exhibition, please use form 3-200-30).

Electronic submission of inventories, photographs, and receipts: Some applications contain extensive inventories and /or a large number of photographs or receipts. You may provide electronic versions of the documents. Such a submission will assist in expediting the processing of your application since it may reduce data entry by the U.S. Fish and Wildlife Service. If you wish to provide information electronically, please either include media storage containing your information or, once you have received an application number via the e-mailed acknowledgement letter, e-mail your information to [email protected]. Be sure to include the application number provided in the acknowledgement e-mail that will be sent to you when we receive your application.

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 any of the owners of the business (if applying as a business, corporation, or institution), 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.

1. For EACH specimen being exported/re-exported, please provide the following:

Scientific name (genus, species, and, if applicable, subspecies)	Common Name	Qty.	Description of Item (e.g., published description from a catalog or art book)	Size (include unit of measurement)	Date of Manufacture	Date of acquisition (e.g., bill of sale, U.S. Customs import declaration, transferred document)

2. Provide the current location of specimen(s) (address and country):

Name:

Address:

City:

State/Province:

County, Postal Code:

3. What is the purpose of the export?

____ Commercial ____ Personal ____ Other (specify) ______________________

____ Scientific ____ Exhibition

4. Name and address of foreign recipient

Name:

Address:

City:

State/ Province:

County, Postal Code:

5. If protected under CITES, provide documents, signed statement, or other evidence that the specimen(s) was obtained or manufactured prior to the date CITES applied to the item (see pre-Convention definition above).

6. For specimens(s) protected under the U.S. Endangered Species Act (ESA), provide one of the following:

1. For Antiques (see definition above):

1. Provide documentation which shows the age OR a statement from a qualified appraiser attesting to the age;

2. Signed statement that the item has not been repaired or modified on or after December 28, 1973 with any part of any species protected by ESA, AND

3. Documentation showing that the specimen either was imported through a designated antiques port or was in the United States before September 22, 1982 (the date the antiques ports were established).

2. For the non-commercial export of worked African elephant ivory that is part of a household move or inheritance and is not an antique, please provide the following:

   1. Documentation that shows that the ivory used in the specimen was removed from the wild before February 4, 1976 (this may consist of a statement from a qualified appraiser or family documentation), and

   2. If the export is part of a household move, documentation on when the specimen was acquired and how long the specimen has been in your possession OR

   3. If the export is part of an inheritance, documentation on the inheritance, such as a will or legal documents.

3. For the export of all other items that are less than 100 years old (see pre-Act definition above) and that are not African elephant ivory:

4. Has this item entered into commerce (e.g., been bought, sold, or offered for sale by you or anyone else) since December 28, 1973?

If Yes, you must complete form 3-200-37 [http://www.fws.gov/international/permits/by-form-number/index.html].

If No, sign the following certification:

CERTIFICATION STATEMENT original signature is required

I certify to the best of my knowledge and belief that each of the items identified in question 1 was 1) held in captivity or in a controlled environment on December 28, 1973, or the species listing date, if later; 2) that the purposes of such holding were not contrary to the purposes of the Act; and 3) that the wildlife was not held in the course of a commercial activity (if you have questions about this certification statement, please contact the Division of Management Authority).

Applicant's signature: ________________________________________ Date: ____________________

7. If the specimen is protected under the Marine Mammal Protection Act, provide an affidavit and supporting documentation that the item was taken prior to December 21, 1972, as outlined in 50 CFR 18.14 (http://ecfr.gpoaccess.gov/). For cetacean (whales) and pinniped (seals and seal lions; not walrus) specimens, provide either a copy of NOAA Fisheries letter of authorization or evidence that NOAA Fisheries has been contacted.

8. If Re-export provide:

1. A copy of canceled CITES export or re-export document issued by the appropriate CITES office in the country from which the wildlife was imported; and

2. Cleared Wildlife Declaration for Import form 3-177, animal only.

9. Is this shipment a sample collection being exported for temporary exhibition or display purposes and accompanied by a valid ATA carnet?

___NO ___YES - provide ATA carnet document number _____________________.

10. For live animals, the transport conditions must comply with the CITES Guidelines for Transport of Live Animals or, in the case of air transport, with the International Air Transport Association (IATA) live animal regulations (contact airline for information). As such, describe:

    1. The type, size, and construction of any shipping container; and,

    2. The arrangements for watering or otherwise caring for the wildlife during transport.

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

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 Export or Re-Export of Pre-Convention, Pre-Act, or Antique Specimens (CITES, MMPA and/or ESA) application is 45 minutes. 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

1 U.S. Customs and Border Protection (CBP) designated 13 ports for the entry of antiques made of ESA-listed species on September 22, 1982 (19 C.F.R. 12.26). The following ports are authorized: Boston, Massachusetts; New York, New York; Baltimore, Maryland; Philadelphia, Pennsylvania; Miami, Florida; San Juan, Puerto Rico; New Orleans, Louisiana; Houston, Texas; Los Angeles, California; San Francisco, California; Anchorage, Alaska; Honolulu, Hawaii; and Chicago, Illinois.

Form 3-200-23 Rev. 04/2017 Page 7 of 7