Form 3-2378 Federal Subsistence Designated Fishing Application, Perm

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

Federal Subsistence Designated Fishing Application

Permit No.

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 Designated Permit Report

Report Due:

Permit Number:
Season:
Limit:

Did you or a household member use this Permit: Yes _____ No _____

Name

Permit Number

Permittee’s Name:

Location

Gear

Species

Number
Harvested

FWS Form 3-2378 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
PENALTY FOR PRIVATE USE $300

BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 12874 ANCHORAGE, AK
POSTAGE WILL BE PAID BY 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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