3-2355 Waterfowl Lottery Application

OOMB Control. No. 1018-0140
Expiration Date 06/30/2021

FWS Form 3-2355 (Rev. 02/2018)
U.S. Fish and Wildlife Service

WATERFOWL LOTTERY APPLICATION
National Wildlife Refuge System

Follow instructions in the refuge hunt publication; not all fields may be required. Read and comply with all refuge
regulations, including application deadlines.
1. Name of Refuge: _____________________________ 2. Date of Application: _____________________
3. Full Legal Name: _________________________________________________________________________
Mailing Address: ________________________________________________________________________
City: _____________________________ State: ______________________ Zip Code: _________________
Area Code/Phone No: ____________________________________________________________________
Email Address: __________________________________________________________________________
4. Method: ________________________________________________________________________________
5. Hunt Date Choices

6. Hunt Location Choices

st

1 Choice: ______________________________
nd

2

Choice: ______________________________

st

1 Choice: ______________________________
nd

2

Choice: ______________________________

rd

3 Choice: ______________________________

th

4 Choice: ______________________________

th

5 Choice: ______________________________

3 Choice: ______________________________
4 Choice: ______________________________
5 Choice: ______________________________
7. Special Hunt: ___________________________

rd

th

th

7A. Youth Hunt Only: Age Limit at Time of Hunt: ____

8. I have read and understand the refuge hunt regulations and agree to abide by the regulations governing
hunting on the refuge.
___________________________________________
Hunter Signature

________________________________________________
Print guardian name and signature here
(required for hunters less than 18 years old)
----------------------------------------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY

Date Received: ___________________________
Payment Exempt/No Fee

✔

Payment Required

Payment Amount: ________________________
Payment Type:

✔

Personal Check

Cashier’s Check

Money Order

Other:

Notes: _______________________________________________________________________________

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OMB Control. No. 1018-0140
Expiration Date 06/30/2021

FWS Form 3-2355 (Rev. 02/2018)
U.S. Fish and Wildlife Service

NOTICES
All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations
made in the application may be grounds for revocation of the permit and may be punishable by fine or imprisonment (18 U.S.C. 1001).
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as
amended and the Refuge Recreation Act (16 U.S.C. 460k – 460k-4).
Purpose: The collection of contact information is to verify that the individual has an eligible permit to hunt on one of the National
Wildlife Refuges that is designated for waterfowl hunting.
Routine Uses: The individual’s contact information may be used to verify permit status, provide permittees with permit-related
information, and monitor waterfowl hunt activities conducted under a permit. More information about routine uses can be found in the
System of Records Notice, Permits System, FWS-21.
Disclosure: Providing the information is required as a condition of maintaining a Federal permit under the National Wildlife Refuge
System Administration Act. Failure to disclose the requested information may be sufficient cause for revocation of the permit. If the
information indicates a violation of a statute, regulation, rule, order or license, whether civil, criminal, or regulatory in nature, the
information may be transferred to the appropriate Federal, State, local or foreign agency charged with investigating or prosecuting such
violations.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the refuge managers the
information needed to decide whether or not to allow the requested use, and to respond to requests made under the Freedom of
Information Act and the Privacy Act of 1974. The information that you provide is voluntary; however, submission of the requested
information is required to evaluate the qualifications, determine eligibility, and document permit applicants. Failure to provide all
required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. We may not conduct or sponsor and
you are not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has
approved this collection of information and assigned OMB Control No. 1018-0140.
ESTIMATED BURDEN STATEMENT
Public reporting for this collection of information is estimated to average 30 minutes 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike,
MS: BPHC, Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed application to this
address.

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