Form 3-2321 Application/Nomination Form

OMB Control No. 1018-0075
Expires 06/30/2019

Federal Subsistence Regional Advisory Council Membership

APPLICATION/NOMINATION FORM
APPLICANT’S FULL NAME:
MR./MRS.:_______________________________________________________
FIRST
MIDDLE
LAST
Full mailing address:

_

Contact Information:
Home: (907)
Work: (907)
Fax: (907)
E-mail:
Birthdate:

Where is your (or your nominee’s) primary place of residence? (Please note that members
must reside in the region they represent.)
PLEASE ANSWER THE FOLLOWING QUESTIONS (ATTACH ADDITIONAL PAGES IF
NEEDED):
1) Describe your (or nominee's) knowledge of fish and wildlife resources in the region.

2) Describe your (or nominee's) knowledge of customary and traditional uses of
resources in the region.

3) Describe your (or nominee's) knowledge of sport, guided sport, commercial, and other
uses of fish and wildlife resources in the region.

FWS Form 3-2321
Rev. 03/2017

OMB Control No. 1018-0075
Expires 06/30/2019

4) Do you (or nominee) participate in meetings on fish and wildlife issues (for example,
meetings of State fish and game advisory committees, Federal subsistence regional advisory
councils, commercial or sport hunting or fishing organizations, marine mammal commissions,
tribal or corporation resource use groups, caribou working groups, subsistence resource
commissions, coastal resource service areas, waterfowl conservation committees)? If so,
please describe your (or nominee's) involvement.

5) Have you (or nominee) served in an official capacity on councils, boards, committees,
or associations within the past 10 years? If yes, please describe the role you served
while working with these groups (i.e. Chair, Vice Chair, member).

6) The seat you are applying for represents users throughout the region. How would
you (or nominee) find out about fish and wildlife concerns people have and get
information back to those people?

7) Do you (or nominee) use Federal lands for hunting, trapping, fishing, guiding or
transporting, gathering, teaching of traditional knowledge, or other use of fish and
wildlife resources? If yes, please describe which Federal lands you use.

8) Will you (or nominee) travel to and attend Regional Advisory Council meetings at least
two times each year? (Regional Advisory Council meetings are usually held in AugustOctober for fall meetings and and February-March for winter meetings. Transportation and
lodging are prepaid; per diem is provided for food and other expenses.)
Yes____

No____

9) Are you (or nominee) willing to attend Federal Subsistence Board meetings
occasionally? (Board meetings are usually held in January or April. Transportation and
lodging are prepaid; per diem is provided for food and other expenses.)
Yes____

No____
FWS Form 3-2321
Rev. 03/2017

OMB Control No. 1018-0075
Expires 06/30/2019

10) Regional Advisory Council membership should reflect representation of subsistence
and commercial/sport interests. Regional Advisory Council seats are designated for either
subsistence use or commercial/sport representatives. You (or nominee) must choose one or
the other.
____ subsistence
____ commercial/sport
If you are nominating the applicant, please provide your name, your title, and your
organization.

Your Name and Title

Organization

Reference Contacts: Please include three references and their contact information. Please
provide the most current phone numbers available. If you wish, you may also submit letter(s) of
recommendation.
Name:
Organization:
Address:
Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Zip:

Contact Information:
Home: (907)
Work: (907)
E-mail:

Name:
Organization:
Address:

Name:
Organization:
Address:

I certify, to the best of my knowledge, that all statements are correct and complete.

Signature

Date

Please note: All applications must be signed in ink. No application or nomination will be
considered complete without a signature.
Paperwork Reduction Act Statement: We are collecting this information subject to the Privacy Act (5 U.S.C.
552a) and Paperwork Reduction Act (44 U.S.C. 3501. This information collection is authorized by the Alaska
National Interest Lands Conservation Act and associated regulations. The Federal Subsistence Board will use
information that you provide to make recommendations to the Secretaries of the Interior and Agriculture for
appointment of members to the Federal Subsistence Regional Advisory Councils. It is our policy not to use your
name for any other purpose. We will maintain this information in accordance with the Privacy Act, but may release
it under a Freedom of Information Act request (5 U.S.C. 552). Your response is voluntary, but is required to obtain
or retain a benefit. We may not conduct or sponsor and you are not required to respond to this or any other
Federal agency-sponsored information collection unless it displays a currently valid OMB control number. OMB
has approved this information collection and assigned OMB Control No. 1018-0075.
Estimated Burden Statement: Public reporting burden for this form is estimated to average 2 hours per response
including the time it takes to read, gather and maintain data, review instructions and complete the form. You may
direct comments regarding this burden estimate, or any aspects of this form, to the Service Information Collection
Clearance Officer, Division of Policy, Performance, and Management Programs, U.S. Fish and Wildlife Service,
5275 Leesburg Pike, Falls Church, VA 22041-3803. Please do not send your completed form to this address.
FWS Form 3-2321
Rev. 03/2017