Form 3-200-18 Take of Golden Eagle Nests During Resource Development o

Department of the Interior
U.S. Fish and Wildlife Service

OMB Control No. 1018 - 0022
Expires XX/XX/XXX

Federal Fish and Wildlife Permit Application Form
Click here for addresses.

Return to: U.S. Fish and Wildlife Service (USFWS)

Type of Activity: Take of Golden Eagle Nests During Resource Development
or Recovery

 New Application
 Requesting Renewal or Amendment of Permit # __________________
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

2. Date of birth (mm/dd/yyyy)
5.a. Telephone number

3. Occupation

1.d. Suffix

4. Affiliation/ Doing business as (see instructions)

5.b. Alternate telephone number

B.

1.c. Middle name or initial

5.c. Fax number

5.d. E-mail address

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, or institution

4.a. Principal officer Last name

4.b. Principal officer First name

5. Principal officer title

4.c. Principal officer Middle name/ initial

4.d. Suffix

6. Primary contact name

7.a. Business telephone number

7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)

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 $100.00 nonrefundable processing fee if you are applying
for a new permit or $50.00 nonrefundable processing fee if you are requesting a substantive amendment of your existing valid permit). 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))
Do you currently have or have you ever had any Federal Fish and Wildlife permits?
Yes  If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: ______________
No 

2.
3.

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 (No photocopied or stamped signatures)
Date of signature (mm/dd/yyyy)

Please continue to next page
Form 3-200-18

Rev. 4/2017

Page 1of 6

OMB Control No. 1018 - 0022
Expires XX/XX/XXX

SECTION E. TAKE OF GOLDEN EAGLE NESTS DURING RESOURCE
DEVELOPMENT OR RECOVERY
(Bald & Golden Eagle Protection Act, 50 CFR 22.25)
Note: A Federal permit to take golden eagle nests is available only to parties engaged in a resource development or
recovery operation and only when nests are inactive. An inactive nest is one that is not currently used by golden eagles as
determined by the absence of any adult, egg, or dependent young at the nest during the 10 days before the nest is taken.
Please provide the following information numbered according to the questions below on a separate sheet of paper. You
should be as thorough and specific as possible in your responses. Incomplete applications will be returned, delayed or
abandoned.
1.

Describe the resource development or recovery operation in which you are engaged.

2.

Indicate the number of golden eagle nests you propose to take and how they were determined to be inactive. Provide
copies of the monitoring report(s) indicating nest is inactive.

3.

Describe the property on which the taking is proposed, with reference made to its exact geographic location. An
appropriately scaled map or plat must be included which delineates the areas of the resource development or recovery
operation and identifies the exact location of each golden eagle nest you propose to take. The map or plat must contain
enough detail so that each golden eagle nest proposed to be taken can be readily located by the Service.

4.

Describe each activity to be performed during the resource development or recovery operation that involves the taking of
a golden eagle nest.

5.

Indicate the length of time you need the permit to be valid, including the start and ending dates of the resource
development or recovery operation. The permit cannot be valid for a tenure of longer than 2 years.

6.

For each nest you propose to take, calculate the area nesting population of golden eagles and identify on an appropriately
scaled map or plat the exact location of each golden eagle nest used to calculate the area nesting population. (This is not
required if the Service has sufficient data to independently calculate the area nesting population.) The map or plat must
contain enough details so that each golden eagle nest used to calculate the area nesting population can be readily located
by the Service.

7.

Provide a statement with any supporting documents from ornithologists experienced with golden eagles or other qualified
persons who have made on-site inspections and can verify your calculation of the area nesting population.

8.

What is the intended disposition of each nest you propose to take? Are you willing to collect any nests for scientific or
educational purposes?

9.

Provide a statement indicating any proposed mitigation measures that are compatible with the resource development or
recovery operation to encourage golden eagles to reoccupy the site. Mitigation measures may include reclaiming
disturbed land to enhance golden eagle nesting and foraging habitat, relocating in suitable habitat any inactive golden
eagle nest taken, or establishing one or more nest sites. If the establishment of one or more nest sites is proposed,
provide a description of the materials and methods to be used and the exact location of each artificial nest site.

10.

You must retain records relating to the activities conducted under your permit for at least 5 years after the date of
expiration of your permit. Indicate whether the physical address you provided in Section C on page 1 of this application
is the same address where your records will be kept. If not, provide the physical address.

(Continued)
Form 3-200-18

Rev. 4/2017

Page 2 of 6

OMB Control No. 1018 - 0022
Expires XX/XX/XXX

11.

Any permit issued as a result of this application is not valid unless you also have any required State or Tribal
permits or approvals associated with the activity. Indicate whether you have obtained all required State or Tribal
permits or approvals to conduct this activity.
If you have obtained all required approvals, answer “Yes” and attach a copy of the approval(s).
If you have applied for any required approvals, answer “Have applied” and send copy when issued.
If no State or Tribal permits or approvals are required, answer “None required.”

12.

Disqualification factor. A conviction, or entry of 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 disqualifies any such person from
receiving or exercising the privileges of a permit, unless such disqualification has been expressly waived by the Service
Director in response to a written petition. (50 CFR 13.21(c))
Have you or any of the owners of the business, if applying as a business, been convicted, or entered a plea of guilty or
nolo contendere, forfeited collateral, or are currently under charges for any violations of the laws mentioned above?
Indicate “Yes” or “No.” If you answered “Yes” 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.

Form 3-200-18

Rev. 4/2017

Page 3 of 6

PERMIT APPLICATION FORM INSTRUCTIONS
The following instructions pertain to an application for a U.S. Fish and Wildlife Service or CITES permit. 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 blocks/lines/questions in Sections A or B, and C, D, an 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. Some applications may take longer than 90 days to
process. (50 CFR 13.11)
•
Applications are processed in the order they are received.
•
Additional forms and instructions are available from http://permits.fws.gov/.
COMPLETE EITHER SECTION A OR SECTION B:
Section A. Complete if applying as an individual:
•
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 are not required if not available.
•
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, 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) will not accept doing business as affiliations for individuals.
Section B. Complete if applying as a business, corporation, public agency, Tribe, or institution:
•
Enter the complete name of the business, agency, Tribe, 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.
•
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, Tribe, 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. Province and
Country blocks are provided for those USFWS programs which use foreign addresses and are not required by DMA.
•
Mailing address is address where communications from USFWS should be mailed if different than 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 CFR13.11(d)(3). 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. Fees
will not be refunded for applications that are approved, abandoned, or denied. We may return fees for withdrawn applications prior to
any significant processing occurring.
•
Documentation of fee exempt status is not required for Federal, Tribal, State, or local government agencies; but must be supplied by
those applicants acting on behalf of such agencies. Those applicants acting on behalf of such agencies must submit 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 current FWS or CITES permit or the number of the most recent permit if none are currently valid. 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 in blue ink. This signature binds the applicant
to the statement of certification. This means that you certify that you have read and understand the regulations that apply to the permit.
You also certify that everything 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
Form 3-200-18

Rev. 4/2017

Page 4 of 6

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.ecfr.gov and https://www.fws.gov/birds/policies-and-regulations/permits/permit-policiesand-regulations.php)
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), 50CFR 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 a 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.
b.
c.
d.
e.

f.
g.
h.
i.
j.

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 an FWS function related to this system of records.
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.
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.
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.
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.
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.
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.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.
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 a Take of Golden Eagle Nests permit application is 6 hours and 30 minutes for recordkeeping. 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 2.26 – 2.33].

Form 3-200-18

Rev. 4/2017

Page 5 of 6

Migratory Bird Regional Permit
Offices
FWS
REGION

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

AREA OF
RESPONSIBILITY
Hawaii, Idaho, Oregon,
Washington
Arizona, New
Mexico, Oklahoma,
Texas

Iowa, Illinois, Indiana,
Minnesota, Missouri,
Michigan, Ohio,
Wisconsin

Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana,
Mississippi, North Carolina,
South Carolina, Tennessee,
Virgin Islands, Puerto Rico
Connecticut, District of
Columbia, Delaware,
Maine, Maryland,
Massachusetts, New
Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Virginia,
Vermont, West Virginia
Colorado, Kansas, Montana,
North Dakota, Nebraska,
South Dakota, Utah,
Wyoming

Region 7

Alaska

Region 8

California, Nevada

MAILING
ADDRESS

CONTACT
INFORMATION

911 N.E. 11th Avenue
Portland, OR 97232-4181

Tel. (503) 872-2715
Email [email protected]

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Email [email protected]

5600 American Blvd. West
Suite 990
Bloomington, MN
55437-1458

Tel. (612) 713-5436
Email [email protected]

1875 Century Blvd., NE
Atlanta, GA 30345

Tel. (404) 679-7070
Email [email protected]

300 Westgate Center Drive
Hadley, MA 01035-0779

Tel. (413) 253-8643
Email [email protected]

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486

Tel. (303) 236-8171
Email [email protected]

1011 E. Tudor Road
(MS-201)
Anchorage, AK
99503

Tel. (907) 786-3693
Email [email protected]

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
[email protected]