Form 3-200-80 Application - Export of Fertilized Live Eggs, Caviar or

	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 of Fertilized Live Eggs, Caviar or Meat from Aquacultured Paddlefish or Sturgeon (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 of $100, 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. Export of Fertilized Live Eggs, Caviar or Meat from Aquacultured Paddlefish or Sturgeon (CITES)

Note: To request export of species listed under the U.S. Endangered Species Act, submit form 3-200-37.

Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use a separate sheet of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If requesting to authorization for more than one species, please make sure that you respond to each appropriate question for each species.

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 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. Are you requesting authorization for:

______ A single shipment?

______ Multiple shipments?

Single Shipment = $100 processing fee	Multiple shipments = $200 processing fee All processing fees are not refundable	Renewal = $100
Provide Name and address of recipient:	A This application allows you set up a Master File, valid for a maximum of up to three years, for exports of specific amounts of caviar. Once the Master File is approved, you will need to obtain single-use permits, valid for 6 months, for each export (50 CFR 13.11, see attached).
	B How many single-use permits do you anticipate using in the next 6 months upon completion of this Master File review? _____________. (Provide $5 for each 6-month permit).

5. For each species from which product will be exported, provide:

1. Scientific name (genus, species, and if applicable, subspecies) and common name of the fish.

2. State(s) of source specimens.

3. Address where the facility(s) is located.

4. Product description (e.g., fertilized live eggs, caviar, or meat).

5. Weight to be exported (metric and standard units).

6. Description of shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units).

7. Will shipment be fresh, frozen, or pasteurized, or other (describe).

8. Current location of specimen(s).

6. For each facility, provide:

   1. Photos and a description.

   2. Number of years the facility has maintained the requested species.

   3. Provide a copy of the appropriate state, Federal license(s) for the facility.

7. Provide the following regarding your production estimates for each species being requested and each facility identified above:

   1. Number of brood stock spawned annually.

   2. Estimated total weight of eggs produced annually.

   3. Average annual growth rate of fish achieved at the facility.

   4. Biomass, by age class and sex, at the beginning of the year; remaining biomass, by age class and sex, at the end of the year.

   5. Total live stock sold by age class and sex;

   6. Total “green” roe harvested annually (by weight).

   7. Total amount roe determined not to be fit for processing and discarded (by weight).

   8. Total caviar sold domestically (by weight).

   9. Total caviar sold internationally (by weight).

   10. Estimated number of fry produced annually.

   11. Total meat production.

   12. Total meat sold domestically by sex (live weight is acceptable).

   13. Total meat sold internationally by sex (live weight is acceptable).

   14. Mortality rates by age class.

   15. Information regarding disease outbreaks, this information should include the causative agent, if known, percent mortality, relevant pathological findings, and plan to reduce future disease outbreaks.

   16. Sacrifice rates by age class and sex.

6. Provide a statement on how your captive population(s) is being managed to maintain genetic viability.

6. Do you supplement from the wild?

If yes:

1. Provide a copy of the state authorization or collection permit(s) (i.e., aquaculture permit, broodstock permits, and capture logs).

2. What is the disposition of wild-origin fish (males and females) once they have been used to improve the genetic viability of your farm-raised population?

3. When is the last time you supplemented your stock with wild-origin fish?

4. When do you next intend to use wild-origin fish to improve the genetic viability of the population?

6. Provide production records for the previous year.

6. Are all roe that you are exporting F2 generation or more?

6. If you are the Breeder, sign (in ink) the following statement:

I hereby certify that the species listed above to be exported were bred and born/hatched from parental stock at my facility listed below.

Name and address of your facility where the animals were bred and born;

Current location of parental stock:

Signature and date _____________________________________________________________________

6. If you obtained stock from another facility, provide copies of documentation showing that you acquired the specimens from the breeder or documentation demonstrating the history of transactions (chain of ownership of each specimen) and a signed statement from the breeder or breeder's record that includes:

1. Complete name and address of the breeder's facility.

2. Scientific and common name of the species;

3. Statement that the specimen(s) was/were bred and born/hatched at his/her facility;

4. Birth/hatch date, and if applicable band/tag number, or other identifiers;

5. Location (Name, Street address, City, State) of Parental Stock.

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 of Fertilized Live Eggs, Caviar, or Meat from Aquacultured Paddlefish or Sturgeon 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 3-200-80 Rev. 04/2017 Page 6 of 6