FS-2800-22A Application for Permit and Authorization for Paleontolog

FS-2800-22A (REV-02/17)

OMB No. 0596-0082

Office Use Only

Authorization Number:

Click here to enter text.

UNITED STATES DEPARTMENT OF AGRICULTURE

FOREST SERVICE

Application for Authorization for Paleontological Resources Research or Collection

Authorities: 16 U.S.C. §470aaa through 16 U.S.C. §470aaa-11; Organic Administration Act June 4, 1897; 36 CFR 291.13-291.23

1a. Name of Applicant Click here to enter text.	1b. Applicant Affiliation Click here to enter text.
2. Professional contact information Click here to enter text.	3. Contact information in the field Click here to enter text.
4. Nature of paleontological fieldwork proposed: Describe project, including methodology and scope of work: Click here to enter text.
5. Location of proposed paleontological fieldwork (attach 1:24,000 scale topographic map with project boundaries and provide UTM coordinates for known areas of proposed collection or other land surface disturbance) Click here to enter text.
6. Anticipated start date: x		7. Anticipated end date: Click here to enter text.
8. Name(s) of individuals responsible for planning, supervising, and carrying out fieldwork Click here to enter text.
9. Name and address of repository for paleontological resources collected under the proposal Click here to enter text.

10. Additional materials required (should be attached to this application as separate pages):

a. resume for each individual named in line 1a and line 8

b. summary of organizational capabilities

c. summary of organizational history

d. written certification, signed by a properly authorized official (who is NOT named in line 1a or line 8 of this form) of the approved repository named in line 9. This certification will attest that the repository will accept any collections, and as applicable, records, data, photographs, and other documents generated during the proposed work at no cost to the Forest Service, and that the repository will assume permanent curatorial responsibility for such materials on behalf of the United States Government.

Signature of Applicant* Date

_____________________________________________________ __________________

*by signing this application, the applicant agrees to abide by all Forest Service policies and regulations that apply to Forest Service employees and partners which may allow the permittee access to some agency records, including paleontological locality information, but restrict the permittee from public disclosure of paleontological locality information discovered while conducting work under this permit.

BURDEN & NON-DISCRIMINATION STATEMENT

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. The time required to complete this information collection is estimated to average 5.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.

INSTRUCTIONS:

Completing the Application for Authorization for Paleontological Resources Research or Collection

Applicants for a permit to conduct paleontological research and/or collection on Forest Service land should complete Form FS-2800-22A, “Application for Authorization…,” following the instructions below. The completed Form FS-2800-22A should be signed and dated by the applicant where indicated, and returned for agency review to the Forest Service Administrative unit in which the proposed project area is located. Additional information may be requested by the Forest Service in order to complete evaluation of the proposal. The applicant should be aware that proposals entailing land surface disturbance may require an extensive NEPA analysis by agency specialists in order to evaluate potential environmental impacts related to the proposal; such NEPA review may take 6 months or more to complete. THE PROPOSAL IS NOT CONSIDERED AUTHORIZED UNTIL FORM FS 2800-22B (the Permit) HAS BEEN RETURNED TO THE APPLICANT AND HAS BEEN SIGNED AND DATED BY THE APPLICANT AND THE FOREST SERVICE AUTHORIZED OFFICER.

1a. Name of Applicant: Enter the name of the individual who will have primary management responsibility for implementing the proposal and adhering to all terms and conditions.

1b. Applicant Affiliation: Enter the institution or organization with which the individual identified in line 1a is professionally affiliated.

2. Professional contact information: Enter the complete mailing address, telephone number, fax, and email address by which the individual named in line 1a may be contacted at the institution identified in line 1b.

3. Contact information in the field: Describe means by which individuals identified in line 1a and/or line 8 may be contacted while in the field conducting authorized field work

4. Nature of paleontological fieldwork proposed: Describe the proposed activity in detail, including objective(s), scope of work and methodology. The description should contain sufficient detail for an agency reviewer to evaluate the extent of potential land surface impacts related to the proposed work.

5. Location of proposed paleontological fieldwork: Provide an accurate description of the area where field activities are proposed. Location should be depicted on an attached 1:24,000 scale topographic map showing complete project boundaries. UTM coordinates of known areas proposed for collection or other surface disturbance should be provided separately from the map. Alternatively, the project location description may be transmitted in a digital format which is compatible with existing Forest Service software and which must be approved in advance by the FS project reviewer.

6. Anticipated start date: Enter anticipated start date of proposed field activities. If proposed activities will encompass more than one field season, enter anticipated start dates of each field season.

7. Anticipated end date: Enter anticipated end date of field activities. If proposed activities will encompass more than one field season, enter anticipated end dates of each field season.

8. Name(s) of individuals responsible for planning, supervising, and carrying out fieldwork: Enter the names of all individuals anticipated to participate in the proposed field activities, including the individual identified in item 1 if s/he plans to participate in the proposed field activities.

9. Name and address of approved repository: Enter the name and address, including phone number and e-mail contact information, for the institution which has agreed to accept and provide appropriate long term curation of all paleontological resources collected under the authorized proposal (such collections remain Federal property). Enter N/A if no collecting is proposed. Applicant’s selection of a repository institution is subject to Forest Service approval.

10. Additional materials required (should be attached to the application as separate pages):

a. resume for each individual named in line 1a and line 8: Provide a resume or curriculum vitae for all individuals identified in lines 1a and 8. These will be used to determine the qualifications and eligibility of the identified individuals to carry out the proposed activity.

b. summary of organizational capabilities: Describe the capabilities of the individuals identified in lines 1a and 8 and the organization identified in line 1b to provide required logistical/infrastructure support for the proposed activity.

c. summary of organizational history: Describe the experience of the individuals identified in lines 1a and 8 and the organization identified in line 1b pertaining to management of prior activities similar to the proposal. If collection is proposed, also describe the experience of the institution identified in line 9 in curating paleontological collections similar to the proposed collection.

d. written certification, signed by a properly authorized official (who is NOT named in line 1a or line 8 of this form) of the repository named in line 9, attesting to the repository’s willingness to accept any collections, and as applicable, records, data, photographs, and other documents generated during the proposed work, and to assume permanent curatorial responsibility for such materials on behalf of the United States Government: The repository institution identified in line 9 must provide a written document, signed by an authorized representative of that institution not otherwise named in the permit application, certifying that the institution agrees to accept and curate all of the paleontological resources and associated data collected under the authorized proposal, and acknowledges that such collections remain Federal property. The Forest Service may request documentation from the institution that bears on its capability to provide appropriate curatorial services for the proposed collection. Such documentation could include, but not be limited to, a description of the institution’s scope of collections, collections management plan, staff résumés, and institutional accreditation documents.

Page 1 of 1