Form 3-200-64 Application - Certificate of Ownership for Personally Ow

	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: Certificate Of Ownership For Personally Owned Wildlife "Pet Passport" (CITES) ____New Application (Re-issuance use application 3-200-52) ____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 $75, 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)

Please continue to next page

E. CERTIFICATE OF OWNERSHIP FOR PERSONALLY OWNED WILDLIFE "Pet passport" (CITES)

Note: This form is used to request a passport-like certificate for a single animal (one pet per application).

• Your primary residence must be in the United States (i.e., residing the majority of the year in the United States) to be eligible for this certificate.

• Certificates cannot be re-issued if the pet is currently outside the United States; therefore the pet must return to the United States prior to the expiration of the certificate.

• Certificates issued are typically valid for three years, and are intended for multiple border crossings.

If you are interested in obtaining a single permit for multiple animals without needing multiple crossings, or are intending to move your pet overseas permanently, please use form 3-200-46 (http://www.fws.gov/international/permits/by-form-number/index.html).

Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use separate sheets of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. A separate application and certificate is needed for each animal.

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), 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, or convicted, or entry of 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? Or have you forfeited collateral, or are currently under charges for any violations of the laws mentioned about?

No Yes

4. If you answered “Yes” to Question 2, 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” answer does not automatically disqualify you from getting a permit.

1. Provide the following information (note: In most cases, your animal must be permanently marked to qualify for a Certificate of Ownership):

Scientific name (genus, species, and, if applicable, subspecies)	Common Name	Birth/Hatch date mm/dd/yyyy	Sex	Permanent marking1 and/or name	Household name	Source (wild/ captive-born)

2. What is the current location of your pet?

3. Indicate date of travel and country or countries of destination (if currently known):

ORIGIN OF YOUR PET: answer question 7 if your pet was wild-caught; question 8 if your pet was captive-born; and question 9 if you do not know the origin of your pet.

4. For animals that were wild caught:

a. If your pet was removed from the wild within the United States, provide:

i. Evidence that it was legally acquired (State authorization);

ii. The purpose for which the animal was removed from the wild; and

iii. The date the animal was removed from the wild.

iv. Documentation demonstrating the history of transactions (e.g., chain of ownership(s) of animal).

b. If your pet was removed from the wild outside the United States, provide:

i. Country of origin;

ii. Evidence that it was legally imported into the U.S. (please refer to question 10); and

iii. The date you acquired the animal.

iv. Documentation demonstrating the history of transactions (e.g., chain of ownership(s) of animal).

5. For animals that were captive-born:

a. Provide a dated and signed statement from the breeder that includes the following:

i. Scientific and common names of bird;

ii. Hatch date, band/tag number or identifying markings, and sex of the animal;

iii. Name and address of the facility where the animal was bred and born;

iv. Location of parental stock; and

v. A statement that the animal was bred at the above facility.

vi. In addition, provide documentation demonstrating the history of transactions (e.g., chain or ownership of pet(s)).

6. If you do not know the origin of your pet, provide a signed and dated statement with a complete description of the circumstances under which you acquired the pet, including when, where, from whom, and any other pertinent information. Include pet store receipts or other information that would assist in determining the source of your pet.

7. For animal previously imported into the United States (i.e., did not originate from the United States), provide evidence that the animal was legally imported, including:

   1. Copies of validated canceled CITES export permits or re-export certificates issued by the appropriate CITES office in the country from which the wildlife was imported, and a copy of the cleared Declaration for Importation (form 3-177).

   2. If you did not make the original import, provide copies of the importer’s documents outlined above and any invoice or other documents that show you purchased or otherwise obtained the wildlife from the original importer.

   3. If you did not obtain the wildlife from the original importer, include documentation demonstrating the history of transactions.

   4. For exotic birds previously imported, provide a copy of the Wild Bird Conservation Act (WBCA) import authorization.

8. If requesting a passport for a species listed on the Migratory Bird Treaty Act (listed in 50 CFR 10.13), provide Federal and/or State permit(s) or license numbers that authorize possession and acquisition

9. 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 airlines for additional information). Please provide a description of the shipping conditions including:

   1. The type, size, and construction of any shipping container; and

   2. The arrangements for watering or otherwise caring for your pet during transport.

10. When travelling with your pet, there may be animal health requirements specific for that destination. As soon as you know your travel details, contact your local veterinarian to assist with the pet travel process. Factors to consider may include meeting time frames for obtaining a health certificate, updating vaccinations, diagnostic testing, or administration of medications/ treatments. Please contact Dept. of Agriculture Animal and Plant Health Inspection Service (https://www.aphis.usda.gov/aphis/pet-travel)

11. Be aware that certain States require pet possession certificates. Contact your State conservation agency for pertinent requirements, and submit copies of applicable documentation with your application.

12. All international shipment(s) of wildlife must be declared to the U.S. Fish and Wildlife Service at the time of export/import. A list of designated ports (where a wildlife inspector is posted) is available from http://www.fws.gov/le/designated-portshtml.

13. If you wish to use a port not listed, additional authorization to use a non-designated port will be required. If you wish to use several different non-designated ports, you may be required to contact the Office of Law Enforcement for additional authorization.

14. Enter the U.S. port(s) through which the [export/re-export/import] is anticipated to occur:_____________________________________________________________.

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 Certificate of Ownership for Personally Owned Wildlife “Pet Passport” (CITES) application is 30 minutes. 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 (e.g., tattoo number; band number; microchip number, type, and location on animal; prominent scars. Some pets, such as snakes, may not be suitable for permanent marking such as microchips or tattoo. Prominent coloration or markings that distinguish the animal from others of it species may be sufficient.)

Form 3-200-64 Rev. 04/2017 Page 6 of 6