Form 3-2275 Title 50 Importation Request Form

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

Form 3-2275 (Rev. 12/2019)
U.S. Fish and Wildlife Service

Title 50 Importation Request Form

(Approvals will only be granted upon receipt of a valid Title 50
Health Certification and after consultations with the State resource
agency of the state receiving the eggs or animals)

U.S.
F1SH & WILDLIFE
SERVICE

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Anticipated Date of Import:__________________________________________________________
Company/Agency Receiving Animals or Eggs: _________________________________________
Name of Facility to Receive Animals or Eggs:__________________________________________
Address of Facility:
________________________________________________________________________________
Import Request:
Number: __________

Life Stage: __________

Species: _____________________________

Number: __________

Life Stage: __________

Species: _____________________________

Number: __________

Life Stage: __________

Species: _____________________________

Number: __________

Life Stage: __________

Species: _____________________________

Number: __________

Life Stage: __________

Species: _____________________________

Number: __________

Life Stage: __________

Species: _____________________________

Origin of Eggs or Fish:

___________________________________________________________
___________________________________________________________

Name and Address Importer
Signature: ___________________________________________ Date: _____________________
Name: _______________________________________
Address: _____________________________________
City: _________________________________
State: __________________ Zip Code: ____________
Phone: _______________

Fax: _______________

Title: ___________________________
Please Return To:
U.S. Fish and Wildlife Service
Division of the National Fish Hatchery System
5275 Leesburg Pike
Falls Church, VA 22041
USA

Form 3-2275 (Rev. 12/2019)
U.S. Fish and Wildlife Service

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

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 contact information collected is to track and control salmonid fish importations.
Routine Uses: The collected information is used to track and control fish or fish reproductive products importations and to
ensure the safety of the shipment. 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 required to obtain or retain a benefit.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the U.S. Fish
and Wildlife Service the information necessary to consider your request to import salmonids or their eggs 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 3-2275 is 15 minutes, 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.