Form 3-200-75 Application - Registration of a Production Facility for

	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: Registration of a Production Facility for Export of Certain Native Species (Convention on International Trade in Endangered Species) Multiple Commercial Shipments ___ New Application ___ Amendment or Re-issuance of Master File # ___________

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 $50, 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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E. REGISTRATION OF A PRODUCTION FACILITY FOR EXPORT OF NATIVE CITES SPECIES

This application is to be used by qualified production facilities to establish an annual registration, or master file, to export certain native species (if requesting authorization for sturgeon or paddlefish, please use form 3-200-76 or 3-200-80 (http://www.fws.gov/international/permits/by-form-number/index.html). The master file will allow the registrant to obtain a number of single-use CITES export documents (at a cost of $5 each) for approved species. Please contact the Division of Management Authority or see our webpage at http://www.fws.gov/international/permits/by-form-number/index.html for a list of qualified species and conditions that must be met to qualify for registration, or to answer any questions you may have.

The U.S. FWS may not be able to issue CITES documents for the commercial export of Appendix-I specimens, unless the specimens were obtained from animals produced at a CITES-registered Appendix-I commercial breeding operation. For more information on registering an Appendix-I commercial breeding operation, contact the Division of Management Authority at 800-358-2104 or [email protected].

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.

I would like to:

___ ESTABLISH A NEW REGISTRATION (Processing Fee = $50)

(This application allows you set up a Master File, valid for one year and renewable, for exports of certain native species under CITES. 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))

____ RENEW AND/OR AMEND AN EXISTING REGISTRATION, FILE # _______________ (Processing Fee = $50)

For either the establishment of a new registration or renewal/amendment of an existing registration, please indicate the number of single-use permits you anticipate using in the next 6 months? _____________

(Provide $5 for each 6-month permit.) Additional permits may be requested by submitting form 3-200-74 (http://www.fws.gov/international/permits/by-form-number/index.html).

Please respond to each of the following questions and provide all information requested. Mark questions that are not applicable with “N/A”. If needed, use separate sheets of paper. Please indicate the question number you are addressing on all attachments or separate sheets you submit. If you are applying for multiple species, be sure to indicate which species you are addressing in each response.

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. Scientific (genus, species, and if applicable, subspecies) and common name of species to be registered.
   
   

5. Description of all products and/or specimens to be exported (e.g., live, whole carcasses, meat). If live, what are the typical sizes being exported (e.g., hatchlings, sub-adults, adults)?

FOR APPENDIX III GRAPTEMYS SP. (MAP TURTLES) AND MACROCHELYS TEMMINCKII (ALLIGATOR SNAPPING TURTLES):

Provide the information requested in 3 and 4 if the registration is for a species listed in Appendix III.

6. Location of farm or production facility (physical address, including county).

Name:

Street Address:

City/County:

State:

Zip Code:

7. Copies of any licenses or permits required for your farm or production facility under Federal, Tribal, State, or local laws or regulations.

FOR ALL CAPTIVE-BRED APPENDIX II SPECIES AND OTHER CAPTIVE-BRED APPENDIX III SPECIES:

Provide the information requested in 8 through 16 if the registration is for a species listed in Appendix II or Appendix III species other than Graptemys sp, and Macrochelys temminckii.

8. Location of farm or production facility (physical address, including county):

Name:

Street Address:

City/County:

State:

Zip Code:

9. Description of your production system (e.g., how your specimens are produced; number of male and female breeding stock maintained at your facility; whether you supplement your stock with individuals collected in the wild; if supplemented from other sources, provide those sources and how often you supplement).

10. Copies of any licenses or permits required for your farm or production facility under Federal, Tribal, State, or local laws or regulations.

11. If the specimens for export are captive-bred, provide:

a) Evidence the animals were captive-bred (e.g., breeder’s records, signed breeder’s statement, ISIS documents)

Please note: If you are not the breeder of the wildlife, you must submit breeder’s records and copies of invoices or other documents showing that you acquired the wildlife from the breeder. If there have been several owners, show the history of transactions including invoices for each change of ownership from the time the specimen was harvested until the time you purchased it.

b) Evidence that your founder stock was legally taken (e.g., State license and tag number)

c) Purpose founder stock was removed from the wild

d) Where founder stock specimens were taken (exact location)

e) Date they were taken

f) Gear used to capture founder stock specimens

12. Estimate of your production and export of specimens for the coming year. If dealing with more than one type of specimen, please provide estimates for each of them.

13. Normal mortality rates at your facility. If you have experienced unexpected or higher than normal mortality rates, disease breakouts, or contaminant events at your facility during the past five years please provide a brief discussion.

14. As the Breeder, sign (in ink) the following statement:

I hereby certify that the animal(s) submitted on this application to be exported was bred and born/hatched from parental stock at my facility listed below. (Additional information on the parental stock may be requested upon receipt of your application).

Name and address of your facility where the animals were bred and born/hatched:

Name:

Street Address:

City/Providence:

State, Zip Code:

Current location of parental stock:

Name:

Street Address:

City/Providence:

State Zip Code:

Signature ________________________________________________________Date __________________

15. If you are NOT the breeder of the specimen(s), provide copies of documentation showing that you acquired the

Animal(s) from the breeder or documentation demonstrating the history of transactions (chain of ownership of each animal) and a signed statement from the breeder or breeder's record that includes:

a. that the animal was bred and born/hatched at his/her facility;

b. birth/hatch date, and, if applicable, band/tag number, or other identifiers;

c. sex of each specimen he/she bred;

d. location (Name, Street address, City, State) of Parental Stock;

e. complete name and address of the breeder's facility.

16. Provide labeled photographs depicting the facilities for the specimens described in your application.

FOR WILD-COLLECTED APPENDIX II SPECIES AND OTHER WILD-COLLECTED APPENDIX III SPECIES:

Provide the information requested in 17 through 20 if the registration is for a species listed in Appendix II or Appendix III species other than Graptemys sp, and Macrochelys temminckii.

16. For specimens taken from the wild, provide:

1. a) Evidence that the specimens will be legally taken (e.g., State license, collection permits)

2. b) Purpose for removal from the wild

3. c) State and county/parish (if known) where specimens will be taken

4. d) Dates specimen are typically taken

5. e) Gear used to capture specimens, if applicable

16. Provide a description of your production facility (e.g., do you remove specimens for the wild for immediate export; do you maintain specimens until they are a large size; do you sell live animals, skins, or meat)

16. The export of some CITES species require that skins be tagged before being exported. If that is the case with your specimens, we will either request a list of tags while we are processing your application or, if approved, have you incorporate the list on the face of the permit that we issue.

16. The transport conditions for live animals 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). As such, describe:

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

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

All exports and re-exports 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 Registration of a Production Facility for Export of Certain Native Species 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

Form 3-200-75 Rev. 04/2017 Page 7 of 7