Form 3-200-29 Application - Export/Re-Export of Wildlife Samples and/o

	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/Re-Export/Master File of Wildlife Samples and/or Biomedical Samples (CITES) ____ Export ____ Re-export ____ New Master File ____ Amendment of Master File # _______________ ____ Renewal of Master file # ________________

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 laid out on page 3, 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)

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E. Export/Re-Export of Wildlife Samples and/or Biomedical Samples (CITES)

For the export/re-export of samples from species listed under the Endangered Species Act or CITES Appendix I species (50 CFR Part 17), use application form 3-200-37 [http://www.fws.gov/international/permits/by-form-number/index.html].

The U.S. FWS may not be able to issue CITES documents for the commercial export of Appendix-I specimens, unless the specimens were obtained from animals produced at a CITES-registered Appendix-I commercial breeding operation. For more information on registering an Appendix-I commercial breeding operation, contact the Division of Management Authority at 800-358-2104 or [email protected].

Use this form if you are collecting in the open ocean on a U.S. registered vessel and transporting the specimens directly to a different country - your shipment would require a U.S. CITES export permit. In addition, if you are exporting Appendix-I specimens, an import permit issued by the country into which the specimens are transported would be required.

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 a disk 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.

_____ I will be submitting documents electronically.

Provide the following information. Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use separate sheets of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If you are applying for multiple specimens, be sure to indicate which specimen you are addressing in each response.

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.

This application can be used to:

Request a single-use permit for export of samples (processing fee = $100) that is valid for 6 months from the date of issuance. For re-issuance or amendment of a single use permit, the original permit must be returned with this completed application form.

Request a single-use permit for re-export of samples [e.g., samples that were previously imported into the United States or taken from animals previously imported] (processing fee = $75) that is valid for 6 months from the date of issuance. For re-issuance or amendment of a single use permit, the original permit must be returned with this completed application form.

Establish a Master File (processing fee = $200 + $5/partially completed certificates): A “Master File” can be valid for up to 3 years from the date of issuance. Once the Master File is approved, you must obtain partially completed certificates to export or re-export samples. Partially completed certificates are $5 each, are valid for 6 months. Certificates must be obtained prior to making any shipment and must accompany the shipment.

Amend an existing Master File (processing fee = $100 + $5/partially completed certificates): A “Master File” must be amended when there have been any changes to the information provided in the original application for a master file. You need only provide the requested information for the changes that need have occurred. However, if you intend to renew your current Master File at the same time you are amending it, see below.

Renew (or Amend and Renew) a Master File (processing fee = $100 + $5/partially completed certificates): To renew a Master File that has or will soon expire, you must complete this entire application, including providing all of the information requested in this form for all plants to be included in your Master File and information on any changes to your facility, operations, species, or suppliers for the plant specimens that you wish to export.

What activity are you requesting authorization to carry out?

____ SINGLE SHIPMENT for export (Processing Fee = $100)

____ SINGLE SHIPMENT for re-export only (Processing Fee = $75)

____ ESTABLISHING A MASTER FILE (Processing Fee = $200)

____ AMENDMENT OF AN ESTABLISH MASTER FILE, # (Processing Fee = $100)

____ RENEWAL OF AN ESTABLISH MASTER FILE, # (Processing Fee = $100)

____ AMENDMENT and RENEWAL OF AN ESTABLISHED MASTER FILE, #___________ (Processing Fee = $100)

____ AND Number of partially completed certificates requested at this time: ______ ($5 each)

Additional partially completed certificates may be requested by submitting form 3-200-74

(http://www.fws.gov/international/permits/by-form-number/index.html). All processing fees are nonrefundable.

1. If requesting a single-use permit, provide the name and address of foreign recipient (if shipping to yourself, include your foreign address):

Name:

Business Name:

Address:

Address:

City:

State/Province:

Country, Postal Code:

2. If requesting renewal, amendment, or establishment of a Master File, please be aware that partially completed permits must be issued off of the master file in order to ship the requested specimen(s). Considering that partially completed permits are only valid for a 6-month period, please specify the number you are requesting at this time: ______ (Provide an additional $5 per requested permit).

3. For EACH animal from which samples are to be shipped, provide the following (You may use the attached corresponding inventory sheet): Please do NOT include Quarantine, Immunization or Health records unless they document transfer of ownership. (See sample inventory page provided.)

a. Scientific name (genus, species, and, if applicable, subspecies);

b. Common name;

c. Animal's microchip, tag, band, or other identification number or House name;

d. Sex, if known;

e. Birth/hatch date or age class;

f. Source of specimen (Wild or Captive-Born);

g. If animal or specimen was previously imported into the United States, foreign CITES export permit number and issuance date associated with that import;

h. Type of sample (e.g., blood samples, cell cultures, tissue samples); and

i. Quantity of samples & how packaged (e.g., 10 1-ml flasks, paraffin blocks, slides).

4. What is the purpose of the export?

____ Commercial ____ Scientific

____ Other (specify: _____________________________)

5. Where is/are the specimen(s) currently located?

Name:

Address:

City, State/Province:

County, Postal Code:

6. For wildlife previously imported into the United States from another country, provide:

a. All copies of canceled CITES export or re-export documents issued by the appropriate CITES office in the country from which the wildlife was exported,

b. All copies of cleared wildlife Declaration for Import (Form 3-177),

c. Copies of Inventory sheets that accompanied the original shipment showing original tattoo #’s, and

d. If you did not make the original import, provide copies of the importer's documents outlined above and the invoices or other documents that shows you acquired the wildlife from the original importer or history of transactions (chain of ownership).

7. For samples collected from animals born in the wild in the United States, provide:

1. Have the specimens been collected? If not, when will they be collected?

2. Specific location of where, when and by whom (name and address) the animal/sample was removed from the wild,

3. A description of the method(s) of collection, including previous results using this methodology (e.g. mortality rate, adverse impacts). If mortality occurred, how was the methodology modified to reduce future incidences of injury or death? If the animal was removed from the wild and held for an extended period in captivity, describe the length of time the animal was held in captivity and, if still in captivity, the location and future disposition of the animal,

4. The qualifications of the individuals collecting the animal or samples,

5. A copy of any applicable local, Tribal, State, or Federal government authorization approving the activity, and

6. Documentation that the applicant legally acquired the animals/samples.

8. For samples collected from animals born in captivity within the United States:

1. Have the specimens been collected? If not, when will they be collected?

2. A description of the method(s) of collection, including previous results using this methodology (e.g. mortality rate, adverse impacts). If mortality occurred, how was the methodology modified to reduce future incidences of injury or death?

3. The qualifications of the individuals collecting the animal or samples,

4. A copy of any applicable local, Tribal, State, or Federal government authorization approving the activity,

If you are the breeder, please provide a dated statement that the animal was bred and born at your facility. This statement must include:

1. Name and address of the breeding facility;

2. Birth/hatch date, band/tag number, and sex of each specimen; and

3. Signature of the attending veterinarian or animal caretaker in charge of the breeding operation.

If you are NOT the breeder of the animals, provide copies of documentation showing that the specimens were legally acquired, such as documentation that demonstrates the history of transactions (e.g., chain of custody) and a dated signed statement from the breeder or breeder's record that includes:

1. Complete name and address of the breeder's facility;

2. Scientific name; birth/hatch date, sex, and, if applicable, band/tag number or other identifier of each specimen bred;

3. Statement that the animal was bred and born at the breeder’s facility;

d. Location (name of holder, city, State, zip code) of parental stock;

e. Whether the parental stock was captive-born or wild-caught; and

f. Signature of the attending veterinarian, or animal caretaker in charge of the colony.

9. For marine mammals samples, provide a copy of your FWS or NOAA Fisheries permit or authorization.

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).

Please do not submit handwritten inventories with your application. You may re-create this spreadsheet as long as it contains all the necessary information.

Export/Re-export of Wildlife Samples (CITES)

INVENTORY PAGE

a. Scientific Name

(genus, species, subspecies)

b. Common Name

c. Original Animal Number

d. Current Animal Number

e. Gender

f. Source Code

(Wild or Captive-Born)*

g. Birth Date(mm/dd/yyyy)

h. CITES

Export Permit No. (If

re-export)

i.

Export Permit Issuance Date (If re-export)

j. Type of Sample

(blood, tissue, DNA)

k. Quantity of samples & how Packaged

(vials, slides, flask)/size and No. of samples

EXAMPLE:

Macaca fascicularis

Crab-eating macaque

RX7272-09

F

W

5/6/1992

VN0101-1998

07/05/98

Liver cells

20 1-ml vials containing 0.5 mls each

Enter column totals for total no. animals, total mls, and total vials/ flasks/ slides, etc:

TOTAL VIALS= TOTAL ML=

If Re-Export use Source Code from the original CITES Export permit.

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 Export/Reexport of Wildlife Samples and/or Biomedical Samples (CITES) application is 2 hours 30 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

Form 3-200-19 Rev. 02/2014 Page 2 of 9