Form 3-200-49 Application - Approval, Amendment or Renewal of a Cooper

	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: Approval, Amendment or Renewal of a Cooperative Breeding Program (Wild Bird Conservation Act)

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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5. Approval, Amendment or Renewal of a Cooperative Breeding Program (Wild Bird Conservation Act)

NOTE 1: This application must be approved before import permits can be issued for the purpose of cooperative breeding. A Cooperative Breeding Program (CBP) must have at least two members. Zoological institutions may be members of a CBP. Once a program is approved, you must submit application form 3-200-48 to request import authorization for specific birds.

NOTE 2: The lead cooperator (as identified on page 1) for the breeding program must submit this application.

Complete all relevant questions on the application. Mark questions that are not applicable with "N/A". Due to the length of some questions, please use separate sheets of paper to answer the application questions. On all attachments or separate sheets you are submitting; please indicate the number of the application question you are addressing. If requesting authorization for more than one species or subspecies, please answer questions 5 – 10 for each species/subspecies.

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.

Are you requesting to:

1. ___Establish a new cooperative breeding program (Please answer all questions)

PROCESSING FEE = $200

2. ___Amend an existing cooperative breeding program; CBP# __________

(If requesting new species, answers questions 1 and 5; If requesting to add a member, answer question 9; otherwise please answer only questions 11 and 12)

PROCESSING FEE = $100

3. ___Renew an existing cooperative breeding program; CBP#___________

(If there are no changes to the membership or species in the CBP, please answer questions 11 and 12)

PROCESSING FEE = $50

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. A description of the species/subspecies to be covered (imported) under the program, including:

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

2. Number of birds requested to meet the goals of the program (Note: indicate the total number of birds to be imported by all the members of the CBP for the life of the program);

3. The minimum number of participating facilities need to achieve management objectives – provide an explanation of how this number was derived; and

4. Desired sex ratio.

5. A statement justifying the need for this approval, which includes information on the current U.S. captive population of the requested species/subspecies and the need for import of additional specimens. Information should include, if applicable, whether there is high trade of the species; it is being captive-bred from re-introduction purposes; you are collaborating with other groups to promote in-situ conservation and the sustainability of the species in the long-term.

6. Provide a description of the cooperative breeding program that includes:

1. Managing genetic diversity is an important component to creating a long-term sustainable captive population. What scientifically grounded method(s) does the CBP intend to use to measure both projected and current levels of genetic diversity within the population? For projected gene diversity, what is the time frame that will be considered (for example, projected gene diversity at 100 years of 10 generations);

2. Description of the long-term plans for developing and maintaining a self-sustaining population in captivity of the exotic bird species;

3. Details on the system of record keeping and tracking of birds and their offspring, including how individual specimens will be marked or otherwise identified;

4. Explanation on the relationship of the cooperative breeding program to the conservation of the exotic bird species in the wild. Include information on whether you anticipate importing captive bred birds or wild caught birds and include identified sources to ensure that the number of birds that you anticipate needing will be available;

5. Information on the long-term funding of the cooperative breeding program to ensure its existence until the CPB’s breeding goals are met; and

6. Detailed plans for the placement of the program birds and any offspring, recalling that birds imported as part of a cooperative breeding program cannot be loaned, sold or otherwise transferred to a non-member without prior authorization of this office. Also, provide a description of how program birds will be dealt with if a member(s) leaves the program or if the program is voluntary terminated (members decide to disband and the program is not renewed) or involuntary terminated (the Service does not renew the CBP).

7. Describe care and maintenance of the requested species/subspecies, and how each prospective member’s facilities meet professionally recognized standards, including (if requesting to amend an established CBP by adding new members, please provide the following for each proposed new member):

1. Name and addresses of each facility where the birds, by species, will be maintained;

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b. In the table below, please provide the requested information for each type of holding space that will be used to house CBP birds. Use one row for each holding space type (flight cages with different dimensions should be listed on separate rows as should indoor vs. outdoor aviaries).

1. CBP member, facility name	2. Aviary type (outdoor vs. indoor flight cage, etc.). Add a separate row for type of aviary.	3. Dimensions of specific aviary/holding space (WxLxH). Please specify units (feet, inches, etc.)	4. How many aviaries fit these specifications?	5. What species will be housed in this type of aviary?	6. How many birds will be housed in each of the aviaries?	8. Will the birds be housed here permanently? If not, please provide additional information in the comments box below (i.e. why will the birds be moved and for how long).
EXAMPLE	Outdoor flight	10’x10’x8’	4	Amazona ochrocephala	Up to 4 birds in two of the flight cages. The two remaining flight cages will be vacant for future imports.	These cages will be used to socialize young birds or for surplus birds
	Outdoor flight	8’x5’x7’	2	Amazona ochrocephala	2	These will be permanent breeding cages and the birds will remain here for multiple breeding seasons. If these birds are transferred we will include that information in our CBP annual report.

3. For each type of aviary listed above, please provide a photo with a caption indicating the ‘type’ as listed in column 3.

3. Please provide information on where any progeny will be housed.

3. Please provide husbandry practices specific to each species as necessary.

f. A qualification statement for EACH individual who will be participating in CBP. This statement should include records showing the participant's prior breeding experience with bird species that are the same or similar to the species in the CBP.

8. Each CBP must identify an appropriate avicultural, zoological, or conservation organization that has agreed to oversee its activities. Please provide a statement from the designated oversight organization, on the organization’s letterhead, that includes at a minimum:

1. Description of the expertise of the organization to serve as an oversight organization;

2. Criteria for acceptance of individuals into the proposed breeding program;

3. How participation in the program will be monitored; and

4. Relationship of the oversight organization to the CBP in establishing and maintaining a self-sustaining captive population of the exotic bird species or enhancing the conservation of the species in the wild.

9. If you are amending or renewing a program, you must also provide the following information in a table format:

1. The number, species, and sex of all birds that have been imported to date for your CBP, including dates of import, countries of origin, disposition of the imported birds for each importer, and associated permit numbers for each permit. Identify the number of birds within each species and their sex held at each facility;

2. For each program participant, a summary of any breeding activity that has been achieved with the imported birds, including the number of eggs and progeny produced, and the disposition of any progeny;

3. For each program participant, a summary of any mortality, including mortality during transit or quarantine (for birds that died in quarantine, you must provide appropriate documentation from USDA/Veterinary Services) of birds imported as part of the approved cooperative breeding program, as well as details of any post-fledging mortality of their progeny;

4. A summary of progress made towards achieving a self-sustaining captive population of each species;

5. An explanation of any substantive changes that have or will occur regarding any aspect of the approved cooperative breeding program; and

6. An official letterhead statement from the designated oversight organization approving the amendment or renewal.

10. Provide a signed and dated statement from each CBP member. The statements must contain the following information:

1. Member name;

2. Scientific name of all species being requested for the program;

3. Statement that the member is aware of the purposes of the cooperative breeding program and the Wild Bird Conservation Act and will abide by the regulations and conditions placed on the program, if it is approved.

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 Approval, Amendment or Renewal of A cooperative Breeding Program (WBCA) application is 3 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 3-200-49 Rev. 04/2017 Page 0 of 9