Form 3-200-33 Application - Export of Artificially Propagated Plants (

	Department of the Interior U.S. Fish and Wildlife Service Federal Fish and Wildlife Permit Application Form		OMB No. 1018-0093 Expires 05/31/2017
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 OF ARTIFICIALLY PROPAGATED PLANTS (Single and Multiple Commercial Shipments) ____ New Application ____ 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 listed on page 2 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 Of Artificially Propagated Plants

This form should be used for the commercial export of cultivated specimens (i.e., species, hybrids, cultivars) of CITES-listed species that meet the criteria of artificial propagation, as defined by CITES Resolution Conf. 11.11 (Rev. CoP15; http://www.cites.org/eng/res/11/11-11R15.php). All plant taxa must be published in a recognized scientific journal or reference that has been adopted by CITES.

This form should NOT be used for:

• To request authorization to re-export artificially propagated plants; or for export or re-export wild-collected plants or plant materials; or for exports or re-exports of plant products (e.g., extracts, powders). Applicants should complete application form 3-200-32 (http://www.fws.gov/international/pdf/permit-application-form-3-200-32-export-re-export-of-plants.pdf).

• To request additional partially completed certificates. Applicants should complete application form 3-200-74 (http://www.fws.gov/international/pdf/permit-application-form-3-200-74-single-use-export-permits-under-a-master-file-or-an-annual-program-file.pdf).

This application may be used to:

Request a single-use permit for commercial export of artificially propagated plants or plant materials (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.

Establish a Master File (processing fee = $200 + $5/partially completed certificates): A “Master File” with an approved plant list is 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 approved plants or plant materials. 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 species or supplier information provided in your existing Master File. You need only provide the requested information for the species or suppliers to be amended (i.e., you do not need to provide information for all of the plants on your approved Master File plant list if it has not changed). 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.

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.

This section is divided into FIVE (5) parts:

• All applicants should complete Parts I and V; and

• To export interspecific and intergeneric hybrids of CATTLEYA, CYMBIDIUM, DENDROBIUM (D. phalaenopsis and D. nobile types only), ONCIDIUM (non-native species only), PHALAENOPSIS, and/or VANDA, complete Part II; and/or

• To export other plants produced at your facility, complete Parts III.

• To export other plants produced at your facility, complete Parts III.

Part I: General information (if more space is needed, attach separate sheets and cross-reference any separate pages by numbering them according to the question you are responding to).

1. Activity for which you are applying:

Request for a single-use permit for commercial export ($100) – please provide the business name, name of contact, and address (street, city, province, country) of the foreign recipient.

Establish a new Master File ($200)

Amend an existing Master File; PRT # _____________ ($100)

Renew an expired/soon to be expired Master File; PRT # _____________ ($100)

Amend and Renew an expired or soon to be expired Master File; PRT # _____________ ($100)

AND

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

2. Name and address where permit should be mailed, if different from page 1. If you want expedited shipping, please enclose a self-addressed, pre-paid, computer-generated, courier service airway bill. Otherwise, all documents will be mailed via the U.S. Postal Service.

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

4. 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.

5. Briefly describe your business, including how long you have been in business and the size, types, and location(s) of growing facilities. Do you propagate all of the plants or plant material exported by your operation? Do you have a single facility or multiple facilities? Are they all co-located? Do you propagate some species/ subspecies/ cultivars/hybrids, while buying other specimens from a single or multiple propagators? Are these purchases on a regular basis (e.g., weekly) or more sporadic? For the specimens you purchase from other producers, do you maintain these species for long periods of time or is there a quick turn-around of these stock? Do you only export specimens obtained directly from a different facility? If so, do you purchase specimens only when you have an order to fill or do you maintain specimens at your facility until such time as an order is submitted?

Provide labeled photographs of your growing facilities, parental stock, and plants included in your application. If you purchase from another facility, please provide such photographs from that supplier(s).

6. Provide copies of the following documentation (cross-reference all document(s) by numbering them according to the question number or plant item number that the document responds to):

• Your current State nursery license.

• Your current U.S. Department of Agriculture Protected Plant Permit (formerly known as General Permit).

• Validated CITES import permits and Phytosanitary Certifications with inventory lists for all plant material imported to the United States.

• Authorizations (e.g. collection permits, land-owner permission, salvage permits) for any wild plant material collected in the United States that is used to establish parental stock.

• Invoices showing the name, address, and telephone number of the person/facility from whom you purchased the plants and the date of purchase for any plant material obtained from other suppliers (including purchases you made to establish parental stock at your facility). If not available, provide a signed propagator’s statement (see sample statement below).

Sample Propagator’s Statement:

I, __________________________ [person’s name], declare that the plant material I provided to _____________ [applicant’s name] on ______________ [date] was propagated from parental stock plants that are maintained at ___________________ [indicate location of parental stock] since _________________ [indicate the year that the parental stock was established]. The parental stock originated from ____________________________________________________________________________ [indicate whether the parental stock was derived from wild or cultivated sources].

[Propagator Signature] [Date]

[Propagator Address]

[Propagator Phone Number or Email]

PART II. Hybrids of Cattleya, Cymbidium, Dendrobium (D. phalaenopsis and D. nobile only), Oncidium (non-native only), Phalaenopsis, and Vanda orchids. Provide information requested in Table 1. All parents must be from these groups, including interspecific and intergeneric hybrids. Refer to Codes below for sections b-d. For all other plants, including other orchid hybrids, proceed to Part III.

TABLE 1. HYBRIDS of CATTLEYA, CYMBIDIUM, DENDROBIUM (D. phalaenopsis and nobile), ONCIDIUM (non-native), PHALAENOPSIS, or VANDA

Item No.	a. Name of Hybrid (Include parental genera or grex)	b. Plant Description at the time of export specify code	c. Growing Environment specify code	d. Propagation Method(s) specify code	e. Name of Propagating Facility
b. Plant Description: 1=Seedling; 2=Juvenile; 3=Mature/blooming; 4=Cutting/division; 5=Root/rhizome; 6= Other (specify) c. Growing Environment: 1 = Greenhouse; 2 = Lathhouse; 3 = Lab; 4 = Field; 5 = Other (specify). d . Propagation Method to produce the specimens to be exported: 1 = Seeds; 2 = Stem or root/rhizome cuttings/divisions; 3 = In vitro; 4 = Other (specify).

PART III. Plants produced and grown at the applicant’s facilities (excluding hybrids in Part II). Provide the information requested in Table 2 for all plants or plant materials requested for export that were produced at your facilities. Refer to the Codes below for sections b-k.

TABLE 2. PLANTS PRODUCED AT THE APPLICANT’S FACILITIES

Information about the plants to be exported

Information about the Parental Stock

Item No.

a. Scientific Name & Common Name (If hybrid, list parental species & hybrid name)

b. Description specify code

c. Growing Environment specify code

d. Propagation Method specify code

e. No. of Parental Stock

f. Growing Environment specify code

g. Origin of Parental Stock

h. Date(s) acquired

i. Quantity obtained

j. Material obtained specify code

How often do you obtain additional stock? (either wild or cultivated)

For cultivated, provide supplier name Provide complete address in Table 4

For wild origin, provide collection location (include nearest U.S. city, county, State; or country)1

b. Specimen Plant Description: 1=Seedling; 2=Juvenile; 3=Mature/blooming; 4=Cutting/division; 5=Root/rhizome; 6= Other (specify) c. Growing Environment of Plants: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify) d. Propagation Method to produce the specimens to be exported: 1=Seeds; 2=Stem or root/rhizome cuttings/divisions; 3=In vitro; 4=Other (specify) f. Growing Environment of Parental Stock: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify) j. Plant material obtained: 1=Seeds; 2=Flasks; 3=Seedlings; 4=Juvenile size; 5=Mature/blooming size; 6=Cuttings/divisions; 7=Roots/rhizomes; 8=Other (specify).

Part IV. Plants produced at facilities other than the applicant’s facilities (excluding hybrids in Part II). Provide the information requested in Table 3 3for all plants or plant materials requested for export. Refer to the Codes below for sections b-k. Use the same plant item number from Table 2, if applicable. If you obtain plants from more than one supplier, use separate lines for each supplier.

Table 3. PLANTS PRODUCED AT DIFFERENT FACILITIES

Information about the plants to be exported

Information about the Parental Stock

Item No.

a. Scientific Name & Common Name (If hybrid, list parental species & hybrid name)

b. Description specify code

c. Growing Environment specify code

d. Propagation Method specify code

e. No. of Parental Stock

f. Growing Environment specify code

g. Origin of Parental Stock

h. Date(s) acquired

i. Quantity obtained

j. Material obtained specify code

How often do you obtain additional stock? (either wild or cultivated)

For cultivated, provide supplier name Provide complete address in Table 4

For wild origin, provide collection location (include nearest U.S. city, county, State; or country)2

b. Plant Description: 1=Seedling; 2=Juvenile; 3=Mature/blooming; 4=Cutting/division; 5=Root/rhizome; 6= Other (specify) c. Growing Environment of Plants: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify) d. Propagation Method to produce the specimens to be exported: 1=Seeds; 2=Stem or root/rhizome cuttings/divisions; 3=In vitro; 4=Other (specify) f. Growing Environment of Parental Stock: 1=Greenhouse; 2=Lathhouse; 3=Lab; 4=Field; 5=Other (specify) j. Plant material obtained: 1=Seeds; 2=Flasks; 3=Seedlings; 4=Juvenile size; 5=Mature/blooming size; 6=Cuttings/divisions; 7=Roots/rhizomes; 8=Other (specify).

PART V. Supplier Information (To be completed by all applicants). Provide the information requested in Table 4. Use the same plant item number from Tables 1, 2, or 3, as applicable. If you obtain plants from more than one supplier, use separate lines for each supplier.

TABLE 4. SUPPLIER CONTACT DETAILS

Item number	Name of Supplier	Full Address (street address, city, state, country, zip code)	Telephone Number	Fax Number (if available)	E-Mail/website (if available)

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 the export of artificially propagated plants application is 2 hours. 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 Include copies of CITES documents, if applicable.

2 Include copies of CITES documents, if applicable.

Form 3-200-33 Rev. 0?/2017 Page 2 of 11