QS Permit Account Renewal Form

OMB Control No. 0648-0620, Expires on: xx/xx/xxxx

QS Permit/Account Renewal Form Pacific Coast Groundfish Individual Fishing Quota

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, West Coast Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.westcoast.fisheries.noaa.gov

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to apply for the renewal of a quota share (QS) permit and account. To complete the renewal process, any Economic Data Collection surveys due from the QS permit owner must be deemed complete by the NOAA/Northwest Fisheries Science Center and the QS permit owner must submit a complete trawl identification of ownership interest form. A QS permit renewal is effective upon approval by NMFS.

1. Legal Name of Quota Share Permit Owner			2. Quota Share Permit Number QS
	3. Business Mailing Address Street or PO Box				4. Business Phone ( )
					5. Business Fax (optional) ( )
	City	State		Zip Code	6. Business Email (optional)

Please sign below to certify that the above information is true, correct and complete (edit if necessary) to the best of your knowledge and return with a complete trawl identification of ownership interest form.

______________________________________________________________________________________________

Signature of Applicant or Authorized Representative Title (If corporate officer) Date

_____________________________________________

Printed Name of Applicant or Authorized Representative

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.

PRIVACY ACT STATEMENT: Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Business phone number, fax number, and email are not released to the public. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated Fisheries. An amended notice was published in the Federal Register on August 7, 2015 (80 FR 47457) and became effective on September 15, 2015 (80 FR 55327).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including the time for reviewing the 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 suggestions for reducing this burden to NOAA/National Marine Fisheries Service, West Coast Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.