Form 3-200-41 Application - Captive-Bred Wildlife Registration/CBW

	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: CAPTIVE-BRED WILDLIFE REGISTRATION (CBW) (U.S. Endangered Species Act) ____New Application ____Requesting Renewal/Amendment of Permit# ____________

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 $200, 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. CAPTIVE-BRED WILDLIFE REGISTRATION (U.S. Endangered Species Act)

Please use the following application for all CBW requests: new or renewals.

All applicants must complete Part 1 of the application. A CBW Registration remains valid for five years and may be renewed once for a total validity of ten years, after which the CBW Registration number will be retired and you must apply for a new CBW Registration. If a renewal application is submitted thirty days or more prior to the CBW Registration expiration, the applicant may continue to conduct previously authorized activities during the renewal process. However, if the application is submitted fewer than thirty days prior to expiration, activities must cease at the time the registration expires until the renewal process is completed.

For New applications and amendments, complete Part 2 of the application. You may renew your CBW once after 5 years, but after a CBW registration has been valid for 10 years, you must submit a complete new application responding to all questions.

To renew your CBW (it has been less than 10 years since you completed a completely new application), complete Part 3 of this application.

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.

Part 1: All Applicants Should Complete

1. The Division of Management Authority annually distributes a list of Captive-Bred Wildlife (CBW) Registration permittees to all CBW registration holders. The list facilitates the exchange of parental stock among registered breeders; and includes permittees that operate as individuals, as well as those that are business entities. For businesses and other organizations holding CBW registrations, including sole proprietorships, the list includes name, permit number, address, and species held by each permittee. However, the records for individuals holding CBW registrations are contained in a Privacy Act (5 U.S.C. 552a) system of records. Therefore, only the name, species, permit number, and state of residence will automatically be included on the list. The complete address will be included only upon authorization from the individual permittees.

If you are not a business or organizational entity, and are applying for the CBW registration as an individual, please provide one of the following statements: (Note: if you collect funds for any wildlife purpose, you are a business)

I, [your name] of [facility name] authorize the U.S. Fish and Wildlife Service to include my complete address in its CBW registration list and to release this information to other CBW holders or the public, if requested. I would also like the Service to use the following address on the CBW registration list: [indicate either your mailing address or facility address as identified in your application].

_____ Same address as on page one.

_____ Different address: _________________________________________________________________________

_____________________________________________________________________________________________

Signed______________________________________________ Date________________

OR

I, [your name] of [facility name] DO NOT authorize the U.S. Fish & Wildlife Service to include my complete address in its CBW registration list. Since my contact information will not be made available to parties interested in cooperating with other CBW holders in breeding programs, I intend to use the following method to communicate and facilitate exchanges with other interested CBW holders: __________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Signed_____________________________________________ Date________________

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.

4. Provide copies of any license or regiatration under the Animal Welfare Act regulations of the U.S. Department of Agriculture (9 CFR 2) (if required) and/or any State license or registration required to maintain or breed the species requested in Part 2 or Part 3 below. If available, provide a copy of your last two (2) USDA AWA inspection reports.

5. The exact location(s), including address(es), where the wildlife requested in this application will be maintained. If more than one location exists, list all that apply. NOTE: You must report any change in address or location of facilities to the Division of Management Authority within 10 days.

6. Provide a current inventory, including those out on loan, for each of the ESA-listed species you are requesting to include or have already been approved (if currently holding a valid CBW registration) on your CBW registration.

7. A description of the qualifications of the individuals who will care for the animals, including the number of years’ experience with this species or similar species, and names of current caretakers.

Part 2: New Application, Amendment, or the Renewal of CBW which are older than 10 years:

FOR EACH SPECIES BEING REQUESTED for inclusion in a registration, whether a new application or amendment, complete each of the following questions. Signify that you have read each question by writing “N/A” if non-applicable. If submitting hard copy pages, please indicate the species and the application question number you are addressing.

5. The scientific name (genus, species and, if applicable, subspecies) and common name of the species.

5. The name, address, and CBW registration number of the person(s) or institution(s) from whom you plan to acquire the wildlife. If currently unknown, state if there is an organized breeding program that you are involved with or if you have communicated with other breeding organizations.

5. Provide a specific description of how your proposed activities are going to facilitate captive breeding for conservation purposes of this species, including your long-term goals for your breeding program and intended disposition of any progeny.

5. Provide documentation or a complete description showing how your captive population is being managed to maintain its genetic vitality. If you do not currently maintain sufficient specimens in each species request to maintain the genetic viability of the species, you must participate in an organized breeding program. Please indicate this program and provide documentation describing the objectives and goals of the program.

5. If your activities include the holding of surplus animals (i.e., no longer needed in the organized breeding program and will no longer be bred) for an organized management program, document how your acquisition of such wildlife will relieve crowding at the locations from which the wildlife will be obtained, and thereby assist the breeding program for the species involved. Provide documentation that you are a participant in an organized breeding program where the holding of surplus wildlife has been identified as a necessary objective of the breeding program. Provide a description of how you will restrict/control breeding at your facility.

5. For each requested species, provide a description of your experience in maintaining and propagating the requested species or similar species, including:

1. The number of years you or the facility has/have maintained the requested species or similar species.

2. During the past five years, how many (by species, by year) successful births/hatches of each requested species or similar species have occurred at your facility? How many survived beyond 30 days?

3. How many mortalities of requested species of similar species, have occurred at your facility during the past five years? What were the causes? What measures have you taken to prevent future mortalities?

4. A brief resume for all senior animal care staff or personnel that will be working with or maintaining of each species requested.

5. Provide a detailed description, including size, construction materials, and protection from the elements, and photographs and detailed diagrams (no blueprints, please) clearly depicting your existing facilities, including space for future progeny, where the wildlife will be maintained.

Part 3: Applications to Renew CBW registrations that are 5 years old or less:

All CBW registrant are required to submit an annual report on activities conducted at the facility over the previous year, as well as a current inventory of all species covered under the registration. If you have already responded to the following questions in your annual report, please note that in your answer to the question.

5. Have there been any changes to your operation such as reconstruction or new construction, new facilities, or other physical changes? If yes, please describe them.

5. Have there been any changes to senior staff or personnel changes that would affect how your operation handles the species included in the registration? If yes, please describe these changes.

5. Have there been any changes to your inventory that has not been reflected in your annual reports or the current inventory list provided to the Service? If yes, please describe these changes.

5. Is there any additional information that you believe the Service should be aware of in regards to your operation, facilities, inventory, or business model?

*** Please note: If you have a change of mailing address you must notify the Service within 10 days. If your facilities move, you will need to apply for an amendment.

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 Captive-Bred Wildlife Registration/CBW 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

Form 3-200-41 Rev. 04/2017 Page 7 of 7