Form 3-2328 Federal Subsistence Fishing Permit

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

Permit No.

Federal Subsistence Fish Application
Federal Land Unit:

Federal Fish Management Area:

Applicant’s Name (First, Middle Initial, Last):

Date of Birth (mm/dd/yy):

Telephone Number:

Mailing Address:

Physical Address:

Community of Primary Residence:

Applicant’s Signature

Issuing Agent (Print):

X ____________________________________________________________________

Date Permit Issued (mm/dd/yy):

I certify that I am a rural resident as defined by 50 CFR 100.4 and 36 CFR 242.4. I have read and understand the conditions
on the permit and agree to comply with them and applicable regulations as found in 50 CFR 100 and 36 CFR 242.

Federal Subsistence Permit and Harvest Report

Report Due:

Permit Number:
Season:
Limit:

Did you fish?
Yes ___ No ___
Did you use a designated fisher? Yes ___

Permittee’s Name:
No ___

Print household members authorized to fish with this Permit (must be Federally qualified subsistence users)

Name (s) _________________________________________________________________________________________________
Gear Legend

Month/
Day

Specific Location

Species Legend

Gear
Code

Species
Code

Number
Harvested

Month/
Day

Specific Location

Gear
Code

Species
Code

Number
Harvested

FWS Form 3-2328 Rev. 03/2017

Conditions of the Permit:

In accordance with the Privacy Act (5 U.S.C. 552a) and the Paperwork Reduction Act (44 U.S.C. 3501), please note the following information. This information collection is authorized by the Alaska National
Interest Lands Conservation Act and associated regulations. The Federal Subsistence Board will use this information to manage fish and wildlife resources for subsistence uses. It is our policy not to use your
name for any other purpose. We will maintain this information in accordance with the Privacy Act. 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 an information collection unless it displays a currently valid OMB control number. OMB has approved this information collection and assigned OMB Control No. 1018-0075.
We estimate it will take you about 15 minutes to complete the application and record your harvest. This burden estimate includes time for reviewing instructions, gathering data, and completing and reviewing
the form. You may direct comments regarding the burden estimate or any other aspect of the form to the 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.

U.S. Fish and Wildlife Service
Office of Subsistence Management
1011 E. Tudor R. M/S 121
Anchorage, AK 99503-6199

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

OFFICIAL BUSINESS
PENALITY FOR PRIVATE USE $300

BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 12874 ANCHORAGE, AK
POSTAGE WILL BE PAID US FISH AND WILDLIFE SERVICE

US FISH AND WILDLIFE SERVICE

Conditions of the Permit:

In accordance with the Privacy Act (5 U.S.C. 552a) and the Paperwork Reduction Act (44 U.S.C. 3501), please note the following information. This information collection is authorized by the Alaska National
Interest Lands Conservation Act and associated regulations. The Federal Subsistence Board will use this information to manage fish and wildlife resources for subsistence uses. It is our policy not to use your
name for any other purpose. We will maintain this information in accordance with the Privacy Act. 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 an information collection unless it displays a currently valid OMB control number. OMB has approved this information collection and assigned OMB Control No. 1018-0075.
We estimate it will take you about 15 minutes to complete the application and record your harvest. This burden estimate includes time for reviewing instructions, gathering data, and completing and reviewing
the form. You may direct comments regarding the burden estimate or any other aspect of the form to the 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.

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