Form 3-200-41A Annual Report - Captive-Bred Wildlife Registration

OMB No. 1018-0093 Expires: ##/##/####

Captive-Bred Wildlife Registration Annual Report for Calendar Year ________

(due by March 31 of following year)

This information includes activities of all species/subspecies listed on your registration, even if they are on loan. Note: Attach a year-end inventory of the listed species (quantity and sex). This form may be copied. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form. Additional information may be attached to the report.

Permittee ________________________________________________ Permit number___________________________

Address (If location/address has changed since last year, indicate new location and date of change):

1. Provide the following information for all activities for the species/subspecies listed on your registration:

Type Of Activity1	Date Of Activity2	Quantity Sex3 (M/F/?)	Scientific Name4	Common Name	Permit No./Name/Complete Address5	Comments
Example: Loan out	4/12/02	1.0	Elephas maximus	Asian elephant	Sunland Zoo and Park	Id no. XXXXXXXX

2. Provide a year-end inventory of all specimens covered under your registration by quantity and sex. Include all specimens that are currently on loan outside your facility.

E-MAIL or Mail YOUR REPORT TO: [email protected] (Reference “CBW Annual Report for PRT #MA________” in Subject Line) Or mail to:

Division of Management Authority, Branch of Permits, 5275 Leesburg Pike, MS-IA, Falls Church, VA 22041-3803.

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 Captive-Bred Wildlife Registration 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

1 Type of activity: Report any activity that affects the number of specimens maintained at your facility -- Births (if survived more than 30 days), deaths (include causes and for euthanasia, include reason for euthanasia in comment column) at your facilities, and then list other types of activities (purchase, sale, loan , donation, gift, trade, export).

2 Date of activity is date it occurred, not necessarily the date specimen was born or transferred.

3 Sex (1.0 = Male; 0.1=female; 0.0.1 = Unknown sex).

4 Include only non-native species listed as Endangered or Threatened under the U.S. Endangered Species Act.

5 CBW Registration number and/or name and address of other CBW registrant involved in the transaction.

Form 3-200-41A Rev. 04/2017 Page 2 of 2