Form 3-200-87 Application - Transfer/Transport of Live Captive-Held Ma

	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: Transfer/Transport of Captive-held Marine Mammals (MMPA)

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 $0 (no fee is required). 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. Notification for and Transfer/Transport of Captive-held Marine Mammals under the Marine Mammal Protection Act (MMPA)

Purpose

Use this application for the domestic transfer of live captive-held marine mammals under the jurisdiction of the U.S. Fish & Wildlife Service (sea otters, marine otter, polar bears, walrus, manatees, and dugong; see http://www.fws.gov/international/pdf/factsheet-marine-mammal-policy-2013.pdf). This application can also be used for the domestic transfer of dead specimens of these species for purposes of public display or scientific research.

For transfer of live animals, the current holder of the animal should use this application to EITHER: (1) provide NOTIFICATION of transfer/transport and/or sale/purchase of an animal that qualifies as public display under the MMPA; OR (2) request a LETTER OF AUTHORIZATION (LOA) to transfer/transport an animal that was originally stranded and needs long-term care at another facility.

For the transfer of dead marine mammal specimens to be used for public display or scientific research, the recipient of the specimens should use this application to request a LETTER OF AUTHORIZATION for the transfer of the specimens to his/her institution/facility. The recipient should complete the application and provide a letter of agreement from the current holder of the dead animal or specimen.

This form should NOT be used for:

• If you are seeking a permit for activities involving marine mammals under jurisdiction of the National Marine Fisheries Service (NMFS) (i.e., whales, dolphins, porpoises, seals, and sea lions), please contact NMFS at http://www.nmfs.noaa.gov/pr/permits.

• For Take¹/Import/Export of FWS-jurisdiction marine mammals for public display, scientific research, enhancement, or rescue/rehabilitation/release activities complete Form 3-200-43.

• For activities involving photography in the wild for educational or commercial purposes, use Form 3-200-86.

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 additional pieces of paper. On all attachments or separate sheets you submit, indicate the application question number you are addressing. If you are applying for more than one animal or specimen, be sure to answer all relevant questions for each specimen.

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. Type of activity requested (check appropriate box):

___ Notification (must be provided at least 15 days prior to any proposed transfer/transport, sale, or purchase)

1. Provide a copy of the original permit and/or the most recent DMA transfer/transport confirmation letter (if not available, provide information about the animal’s lineage); and

2. Indicate the purpose of the proposed activity (public display, scientific research, or enhancement).

___ Letter of Authorization (For non-emergency placements of live animals or transfer of dead specimens, please allow a minimum of 30 days to process your request)

1. Provide the estimated date of the proposed activity.

2. Provide the following for the subject animal/specimen:

   1. Live animal or dead specimen?

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

   3. Name and sex of the marine mammal;

   4. Other identification (e.g., I.D. #, tattoo #, microchip # (provide manufacturer and location of microchip), distinguishing marks/features); and

   5. Estimated or actual birth date of the marine mammal and place of birth or location of take from the wild.

4. Provide the name and address of the receiving facility for live animals or the sending facility for dead specimens and the primary contact’s name, title, and information (phone, fax, and e-mail).

Name of ___Receiving or ___Sending (check one) facility:

Address:

Primary Contact and Title:

Phone/Fax:

E-mail address:

4. If the animal/specimen will be under public display, provide a letter from the receiving facility that contains the following information:

1. The marine mammal will be used in a conservation and/or education program based on professionally recognized standards of the public display community. Please identify which standards are followed: AZA, Alliance, or other professionally recognized standards;

2. The exhibitor’s USDA license/registration number issued under the Animal Welfare Act and expiration date; and

3. The facility is open to the public on a regularly scheduled basis and access to the facility is not limited or restricted other than by charging an admission fee.

4. If the animal/specimen will be used for scientific research provide either the FWS scientific research permit number or the following information. [For research that will be done in an invasive manner on live animals please submit form 3-200-43]:

1. Explain how the research meets the MMPA definition of “bona fide research,” i.e., scientific research on marine mammals, the results of which: (i) are likely to be accepted for publication in a referred scientific journal; (ii) are likely to contribute to the basic knowledge of marine mammal biology or ecology; or (iii) are likely to identify, evaluate, or resolve conservation problems.

2. Attach a copy of the formal research proposal or a detailed description of the proposed project, including objectives, hypotheses, associated methodology, and disposition of the animal or remaining specimen material once your project is complete.

3. Provide the expected research schedule (clearly specify the proposed start and end date(s) of your research and overall duration of the project).

4. Provide a statement with the names and qualifications of the researcher(s) (curricula vitae may be submitted).

4. If the animal will be used for the purpose of enhancing the survival or recovery of the species, provide the FWS permit number.

FOR LETTERS OF AUTHORIZATION FOR TRANSFER OF LIVE ANIMALS ANSWER QUESTIONS 9 THROUGH 11.

4. For the transfer of LIVE animals where the species is new to the receiving facility, provide:

1. A complete description, including photographs and/or diagrams (no blueprints), of the area and facilities where the animal will be held (including the dimensions of pools and haul-out areas);

2. A statement (or attach curricula vitae) about the animal caretakers, which describes their specific experience in the care, handling, and maintenance of this species; and

3. A description of all deaths of FWS marine mammal species at the facility within the past five years and the steps taken to prevent or decrease similar mortalities.

4. Provide the number of animals of this marine mammal (include age and sex) presently maintained at the receiving facility, and whether there is space for additional animals without exceeding USDA/APHIS standards.

4. For placement of a stranded animal at the receiving facility:

1. If this is the initial placement for long-term care and maintenance, provide:

   1. A description of the circumstances regarding the animal’s removal from the wild and the permit or authorization number; and

   2. The information as specified in your permit/authorization if you are requesting that the FWS determine the animal to be non-releasable.

   3. If this is a subsequent placement, provide a copy of the LOA that placed the animal at your current holding facility.

2. Provide a draft transport plan that documents compliance with USDA regulations for transport and care of live marine mammals (7 U.S.C. 2131-2159; 9 CFR 3, Part E) and includes a description of:

   1. the means and duration of the transportation used to move the animal;

   2. the type, size, and construction of all shipping containers used to transport the animal;

   3. the arrangements for watering or otherwise caring for the animal during transport;

   4. the transport contingency plan; and

   5. the qualifications of each person and their responsibilities while accompanying the animal that demonstrates their ability to address the specimen’s needs during transport.

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 Transfer/Transport of Live Captive-Held Marine Mammals application is 1 hour. 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 3-200-87 Rev. 04/2017 Page 7 of 7