Form 3-2273 Title 50 Certifying Official Form

Form 3-2273 (Rev. 12/2019)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

Title 50 Certifying Official Form

(for use by new applicants and those seeking recertification)

&'iv'a»LIFE
FISHSERVICE

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Name: _________________________________________________________________________
Professional Degrees: ____________________________________________________________
________________________________________________________________________________
Position Title: ___________________________________________________________________
Current Place of Employment: _____________________________________________________
Address: _______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Work Phone: ____________________________________________________________________
FAX Number: ___________________________________________________________________
Email Address: _________________________________________________________________
Primary Duties: __________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Area of Expertise & Related Certifications: ___________________________________________
________________________________________________________________________________
________________________________________________________________________________
Facilities Available for Diagnostic Tests: _____________________________________________
________________________________________________________________________________
________________________________________________________________________________

Form 3-2273 (Rev. 12/2019)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0078
Expiration Date: ##/##/####

Available Equipment:

Signature: ______________________________________________ Date: _________________
Return to:

U.S. Fish and Wildlife Service
Division of the National Fish Hatchery System
5275 Leesburg Pike
Falls Church, VA 22041 USA
Attn: Title 50 Certification Form
(If more space is required to adequately answer questions, please use an extra sheet.)
NOTICES
PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the Lacey Act (18 U.S.C. 42) and Title 50, Part 16 of the Code of
Federal Regulations.
Purpose: The information collected is to verify that the applicant has the professional qualifications necessary to evaluate
the health data for salmonid fish and their reproductive parts in the import request process. Qualified Certifying Officials
assist in the effort to protect the aquatic resources of the United States.
Routine Uses: The collected information is to establish and verify the applicant’s eligibility to evaluate the health data of
salmonid fish under 50 CFR 16. More information about routine uses can be found in the System of Records Notice, Permits
System, FWS-21.
Disclosure: Contact information requested on this form is voluntary. However, submission of the requested information is a
condition of receiving or renewing Certifying Official credentials.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501, et seq.) in order provide the U.S.
Fish and Wildlife Service the information necessary to consider your request for certification as a Title 50 inspector under Title
50, Part 16, of the Code of Federal Regulations. Information requested in this form is required to obtain or retain a benefit.
Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is 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 Control No. 1018-0078.
ESTIMATED BURDEN STATEMENT
Public reporting for this collection of information varies depending on the activity for which a permit is requested. The relevant
burden for FWS Form 3-2273 is 1 hour, including time for reviewing instructions, gathering and maintaining data and
completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the
Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS:
PRB/PERMA (JAO), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed
application to this address.