Form 3-200-53 Application - Export/Re-Export of Live Captive-Held Mari

	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: Export/Re-Export of Live Captive-Held Marine Mammals (CITES)

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 provided in E. 4, 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. Export/Re-Export of Live Captive-Held Marine Mammals (CITES)

Purpose

Use this application for the export or re-export of captive-held LIVE marine mammals under the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES). Under the MMPA, marine mammals can only be exported for the purpose of public display, scientific research, or enhancing the survival or species of the stock.

This form should NOT be used for:

• The collection (TAKE¹) of live marine mammals from the wild: To apply for these activities, use form 3-200-43 for U.S. Fish and Wildlife Service-jurisdiction marine mammal species (sea otters, marine otter, polar bears, walrus, manatees, and dugong; see http://www.fws.gov/international/pdf/factsheet-marine-mammal-policy-2013.pdf); or for whales, dolphins, porpoises, seals, and sea lions), contact the National Marine Fisheries Service (NMFS) (see http://www.nmfs.noaa.gov/pr/permits).

• To apply for a CITES permit to export or re-export parts or biological samples, use Form 3-200-29; for import of parts of Appendix-I animals, use Form 3-200-37; and for introduction from the sea, use Form 3-200-31. Provide a copy of your FWS or NOAA Fisheries permit or authorization with your CITES permit application.

All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. If you wish to use a port not listed, please contact the Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).

Please review the complete application carefully before beginning. Provide complete answers to all the questions on the application. If a question is not applicable, answer with “N/A”. If needed, use a additional sheets of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If you are applying to export/re-export multiple animals, be sure to indicate which animal you are addressing in each response.

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.

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 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. For what activity are you requesting authorization to carry out (check the appropriate box):

___ EXPORT = $100 ___ RE-EXPORT = $75

5. Provide the following for EACH animal you are applying:

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

2. Common name;

3. Birth date/Age;

4. Sex (if known);

5. Description (e.g. I.D. #, ISIS #, tattoo #);

6. Country where the wildlife originated;

7. Indicate if the wildlife was originally taken from the wild or born in captivity; and

8. Current location of the specimen.

6. What is the purpose of the export/re-export?

____ Commercial ____ Exhibition ____ Scientific ____ Breeding

7. For animals previously taken from the wild or imported, provide a copy of the Marine Mammal Protection Act (MMPA) permit or other authorization demonstrating that the specimens were legally obtained.

8. For captive-born wildlife, provide an ARKS/ZIMS report OR:

a. If the animal was born at your facility, please provide a statement that includes:

i. Birth date, sex, and identification number of each specimen;

ii. Name and address of your facility where the animal was born;

iii. Location and source (e.g., captive-born, wild-caught) of parental stock; and

iv. Your signature and date.

b. If the animal was born at another facility, provide a signed statement from the facility detailing the origin of the animal and records that include:

i. The complete name and address of the facility where the animal was born;

ii. Birth date, sex, and identification number of each specimen;

iii. Location and source (e.g., captive-born, wild-caught) of parental stock; and

iv. Copies of documentation showing that you acquired the animal from the facility or documentation demonstrating the history of transactions (chain of ownership of each animal).

9. If the specimen is being re-exported (exporting a specimen that was previously imported into the United States) provide:

a. A copy of the canceled CITES export or re-export document issued by the appropriate CITES office in the country from which the wildlife was imported (if applicable); and

b. A cleared copy of Form 3-177, wildlife Declaration for Import (hard copy or electronic release); or

c. If you did not make the original import, provide a copy of the importer's documents outlined above and the invoice or other documentation that shows you acquired the wildlife from the original importer or history of transactions which demonstrate chain of ownership.

10. Provide the name and address of the person receiving the shipment in the foreign country (if self, provide address abroad).

Name:

Address:

City:

Country, Postal Code:

11. If the animal was obtained prior to the date CITES applied to it (“pre-Convention”), provide documents, signed statement, or other evidence to that effect. The listing date can be found at http://www.cites.org..

12. For CITES Appendix-I species, provide a copy of the foreign CITES import permit, or evidence one will be issued by the Management Authority of the country to which you plan to export or re-export the wildlife. (In accordance with Article III of the CITES Treaty, it is required that import permits are issued before the corresponding export permit.)

13. For whales, dolphins, porpoises, seals, and sea lions, provide either a copy of the NOAA Fisheries letter of authorization for export or evidence that NOAA Fisheries has been contacted.

Questions 11 through 16 apply only for the export or re-export of FWS species

14. Provide a copy of the MMPA/ESA permit or authorization for this activity OR provide the appropriate information for question 15, 16, or 17.

15. If the purpose of the export/re-export is for Public Display, provide certification from the importer’s relevant foreign authority (e.g. provincial or national government) that:

1. The foreign recipient maintains their facility for public display of marine mammals;

2. the facility is open to the public on a regularly scheduled basis;

3. access to such facilities is not limited or restricted other than by charging an admission fee; and

4. the recipient offers a program for education or conservation purposes that is based on professionally recognized standards of the public display community (include copies of outreach/educational materials, photos of signage, etc., along with an English translation).

16. If the purpose of the export/re-export is for Scientific Research, provide information indicating that the export of the animal meets the MMPA definition of “bona fide research,” i.e., scientific research on marine mammals, the results of which: (A) are likely to be accepted for publication in a referred scientific journal; (B) are likely to contribute to the basic knowledge of marine mammal biology or ecology; or (C) are likely to identify, evaluate, or resolve conservation problems.

17. If the purpose of the export/re-export is for Enhancement, provide an explanation of how the proposed activities:

1. Will contribute significantly to maintaining or increasing distribution or numbers necessary to ensure the survival or recovery of the species or stock; and

2. Is consistent with any U.S. conservation or recovery plan or the factors that would be addressed in any such plan.

18. Provide a certification from the appropriate government agency of the importing country to show that:

1. The laws and regulations of that government allow enforcement of the U.S. permit conditions;

2. such conditions will be enforced;

3. the government will afford comity to the USFWS to amend, suspend or revoke the permit, if issued; and

4. the documents provided by and about the foreign facility are true and correct.

19. Provide a copy of the letter from the U.S. Department of Agriculture (USDA), Animal and Plant Health Inspection Service, confirming that the foreign recipient meets comparable standards under the Animal Welfare Act for maintenance and care of marine mammals.

FOR ALL APPLICANTS

20. The transport conditions must comply with the CITES Guidelines for Transport of Live Animals or, in the case of air transport, with the International Air Transport Association (IATA) live animal regulations (contact airline for information). You must also meet USDA standards for Humane and Healthful Transport of Marine Mammals. As such, provide:

a. The means and duration of transportation;

b. A description of the type, size, and construction of any shipping container;

c. The arrangements for watering or otherwise caring for the wildlife during transport,

d. The qualifications of the person(s) accompanying the wildlife;

e. Documentation showing compliance with USDA regulations for transport and care of live marine mammals

(7 U.S.C. 2131-2159; 9 CFR 3, Part E).

All international shipment(s) must be through a designated port. A list of designated ports (where an inspector is posted) is available from http://www.fws.gov/le/designated-ports.html. If you wish to use a port not listed, please contact the Office of Law Enforcement for a Designated Port Exemption Permit (form 3-200-2).

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 Export/Re-Export of Live Captive-Held Marine Mammals (CITES) 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 The term, “take,” as defined by the MMPA means to harass, hunt, capture, or kill, or attempt to harass, hunt, capture, or kill any marine mammal.

Form 3-200-53 Rev. 04/2017 Page 7 of 7