Form 3-200-40A Annual Report - ESA Museum Permit

Federal Fish and Wildlife Permit Applications and Reports--Management Authority; 50 CFR 13, 15, 16, 17, 18, 22, 23

3-200-40A ESA Museum Permit Rev 05022017

Annual Report - ESA Museum Permit (Form 3-200-40A) - Government

OMB: 1018-0093

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United States Department of the Interior


FISH AND WILDLIFE SERVICE



Washington, D.C. 20240




OMB Control No. 1018-0093

Expires ##/##/####


Dear ESA Museum Permittee:


Enclosed is your new/renewed Endangered and Threatened Species Museum Permit. Please be sure to read all permit conditions and use the ESA Museum permit correctly. Be aware that this permit only authorizes export and re-import of preserved, frozen, dried, or embedded wildlife specimens or herbarium specimens currently accessioned in your museum.


Reporting Requirements. On an annual basis, permittee must provide a report to the Division of Management Authority that may be submitted as a spreadsheet as described in the below table. Copies of all validated Export/Re-import imports must also be submitted along with the annual report. If there is no activity to report, permittee must provide a signed statement confirming that no export/re-import activities occurred during the year being reported. If reports are not received annually, your permit may be subject to revocation.


Outgoing Specimen Report


Date Sent

Description of specimen

Collection Date

Location where obtained

Acquisition no.

Scientific name and common name

Receiving institution, Country


























Incoming Specimen Report


Date Received

Description of specimen

Collection Date

Location where obtained

Acquisition no.

Scientific name and common name

Sending institution, Country



























If you have additional questions, please contact the Division of Management Authority, Branch of Permits, MS: IA; 5275 Leesburg Pike, Falls Church, VA 22041-3803; phone (703) 358-2104 or fax 703 358-2281.


E-MAIL YOUR REPORT TO: [email protected] (Reference “ESA Museum Annual Report for

PRT #MA________” in Subject Line). Or mail to address on Permit.


FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act – Notice


In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.), 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.shtml.)


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), 50CFR 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. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form.


3. The relevant burden for the report conditioned by an issued Export and Re-import of Museum Specimens permit is 30 minutes. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the report. You may direct comments regarding the burden estimate to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803.



DO NOT RETURN THIS PAGE WITH THE APPLICATION



















Form 3-200-40a Rev. 04/2017 Page 2 of 2

File Typeapplication/msword
File TitleSuggested COSE Reporting Requirements
AuthorAmy Brisendine
Last Modified ByHarlow, Caroline I
File Modified2017-04-26
File Created2017-04-10

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