Form 3-2358 Fishing-Shrimping-Crabbing-Frogging Application/Permit -

F WS Form 3-2358 (Rev. 05/2019) OMB Control. No. 1018-0140

U .S. Fish and Wildlife Service Expiration Date ##/##/####

FISHING - SHRIMPING - CRABBING – FROGGING

APPLICATION/PERMIT

National Wildlife Refuge System

[NAME OF REFUGE]

[Insert address, phone number, email,

website, and/or other pertinent info]

PERMIT (Refuge Use Only)

Permit Number: ___________________ Valid for Season: ___________________________________________

Follow instructions in the refuge fishing publications; not all fields may be required. Read and comply with all refuge regulations, including application deadlines. [Refuge to insert submission instructions and deadline information here.]

Permit Application State Fishing License No.

Date of Application            

Permit Type (Check all that Apply) Location

Fishing Shrimping Crabbing Frogging Other (Describe):            

Contact Informatoin

Full Legal Name

     

Mailing Address City State Zip Code

                       

Daytime Phone (Incl. Area Code) Cell Phone (Incl. Area Code) Email Address

                 

Fishing Locations/Special Events

[Refuges may customize this section with details about fishing locations or special events]

I have read and understand the refuge hunt regulations and agree to abide by the regulations governing fishing activities on the refuge. [Refuges to insert applicable CFR citation for regulations]

_______________________________________

Applicant Signature

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For USFWS Use Only

Date Received: ____________________

Payment Exempt/No Fee Payment Required Payment Amount: ________________

Payment Type: Personal Check Cashier’s Check Money Order Other:      

Notes: __________________________________________________________________________________________

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 deer 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 5 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.