Form 3-200-10a Federal Fish and Wildlife Permit Application Form - Migr

FWS Form 3-200-10a (Rev. 01/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0022
Expires ##/##/####

Migratory Bird Special Purpose - Salvage
(Migratory Bird Treaty Act, 50 CFR 21.27)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

BEFORE FILLING OUT THIS FORM, please access the
Return Addresses (to obtain the email/postal mail
addresses where this form can be returned), review the
Frequently Asked Questions, and read the form
Instructions. Please retain the "NOTICES" page for your
records.

TYPE OF REQUEST
New Application
Renewal
Amendment

If requesting a renewal or amendment, provide Permit #

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See
instruction page(s) for information on how to make your application complete and help avoid unnecessary delays.

Complete if applying as an individual

A.

1.a. Last name

1.b. First name

2. Date of birth (mm/dd/yyyy)

B.

3.b. Alternate telephone number

3.a. Telephone number

1.c. Middle name or initial

1.d. Suffix

3.d. E-mail address

Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution

1.a. Name of business, agency, Tribe, or institution

1.b. Doing business as (dba)

2. Tax identification no.

3. Description of business, agency, or institution

4.a. Principal officer Last name

4.b. Principal officer First name

5. Principal officer title

4.c. Principal officer Middle name/ initial 4.d. Suffix

6. Primary contact name

7.a. Business telephone number 7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City

1.c. State

1.d. Zip code/Postal code:

1.e. County/Province

1.f. Country

2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City

D.

2.c. State

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete

1. A nonrefundable processing fee is required to process this permit, please attach check or money order payable to the U.S. FISH AND WILDLIFE
SERVICE. Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee –
Please see link for processing fee cost and fee exempt status as outlined in 50 CFR 13.11(d). Click here for Processing Fees
2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue:
No
Yes
3. Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and
the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit is complete and
accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.
Signature of applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

Please continue to next page

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OMB Control No. 1018-0022
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FWS Form 3-200-10a (Rev. 01/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM
Special Purpose - Salvage
(Migratory Bird Treaty Act, 50 CFR 21.27)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

NOTE: A Federal Special Purpose Salvage Permit is required to salvage migratory birds that you find dead and had no part in
killing. The permit authorizes temporary possession of the dead specimens for transport to a designated public, scientific, or
educational institution. Possession for personal use is prohibited. You must be at least 18 years old to apply. Please read
“Frequently Asked Questions” and the pertinent regulations before you sign and submit your application.
Please provide the information requested below. If additional information needs to be provided that does not fit in the
designated spaces, add additional sheets to your application submission. You may use as many additional sheets as needed.
Please number pages accordingly using the page number box provided at the bottom of the sheet, and the corresponding
question number.
You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.

SECTION E.
QUESTIONS
1) Attachment - In additions to this form, you should also attach the following to complete your
application:
a) Letter from Principal Officer of institution where birds will be deposited (See question 4)
2) Any permit issued as a result of this application is not valid unless you also have any required State or
tribal permits or approvals associated with the activity. Have you obtained all required State or tribal
permits or approvals to conduct this activity?
Yes, Have Attached
None Required
Have Applied, Will Provide Upon Request
3) Describe the project or activity for which you require this permit, including the location or area where you propose to salvage.

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FWS Form 3-200-10a (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####

4) Depository:
a) Where will your salvaged specimens be deposited? Provide the Federal Permit Number or Explain how you/depository meets the
permit exemption at 50 CFR 21.12.
b) If the specimens will be deposited with an institution other than your own, attach a letter, on the institution’s letterhead, from the
Director or Principal Officer of the institution where the salvaged materials will be deposited. The letter must confirm the institution’s need
for the specimens, that they want you to salvage for them, and describe how they will be used.

5) Anyone who will be assisting you with the permitted activities or acting as your agent must either have their own

Federal migratory bird permit for the activity or be identified by you, in writing, as a subpermittee under your permit.
They may also require a State permit. Subpermittees must be at least 18 years old. As the primary permittee, you will
be responsible for ensuring that your subpermittees are properly trained and adhere to the terms of your permit.
Provide the name of anyone besides yourself who will be conducting activities under your permit.

6) You must retain records legibly written or reproducible in English relating to the activities conducted under your permit for at
least 5 years after the date of expiration of your permit. Is the physical address you provided in Section C on page 1 of this
application the address where your records will be kept?

Yes

No If “no,” provide
the physical address.

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FWS Form 3-200-10a (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####

7) Disqualification factor. Have you, the permittee, or your client (if a broker on behalf of your client):
• Been assessed a civil penalty or convicted of any criminal provision of any statue or regulation relating to the activity for
which the application is filed (50 CFR 13.21(b) (1);
• Been convicted, or entered a plea of guilty or nolo contendere, for a felony violation of the Lacey Act, the Migratory Bird
Treaty Act, or the Bald and Golden Eagle Protection Act. (50 CFR 13.21 (c)(1)):
• Had a permit revoked within the last five years for willfully violating any Federal or State statute or regulation, or any Indian
tribal law or regulation, or any law or regulation of any foreign country, which involves a violation of the conditions of the
permit or of the laws or regulations governing the permitted activity (50 CFR 13.28 (a)(1)) or failing to correct deficiencies
that were the cause of a permit suspension within 60 days (50 CFR 13.28 (a)(2)).
Answer "yes" if ANY of the events listed immediately above have occurred. Answer "no" if none of the events listed immediately
above have occurred.
Yes
No
If you answered “Yes”, provide: a) the individual’s name; b) date of conviction, civil penalty assessment or revocation;
c) charge(s), or reason(s) for revocation; d) location of the incident; e) court (if applicable, ticket, federal/state/tribal court etc.);
and f) legal action taken for each violation (i.e. fine, incarceration, probation…). Please be aware that a “Yes” response does not
automatically disqualify you from getting a permit.

8) Are you eligible for Fee Exempt Status? Fee exempt status applies to government agencies (Federal, State, Tribal,
and municipal governments). Applicants acting on behalf of such agencies must submit a letter on agency letterhead
and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the
applicant will be carrying out the permitted activity for the agency, or the agencies tax exempt form.
Yes - Government Agency
Yes - Acting on behalf of Government Agency
Documentation Included
No - not eligible for Fee Exempt Status

9) I acknowledge that I have read the form Instructions and Frequently Asked Questions, and have accessed the page with the
Return Addresses to obtain the address where I should return this form. I have also filled out all fields and questions in this
application. Check this box to acknowledge:
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OMB Control No. 1018-0022
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FWS Form 3-200-10a (Rev. 01/2020)
U.S. Department of the Interior

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50
CFR 22; the Endangered Species Act (16 U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR
21; the Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;
Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50
CFR 10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities that affect
protected species. The information the individual provides helps the FWS monitor and report on protected species and assess the
impact of permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with
protected wildlife; to provide the public and the permittees with permit related information; to monitor activities under a permit; to
analyze data and produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the
conservation and management of protected species and their habitats; and to evaluate the effectiveness of the permit programs.
More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to
process applications for permits authorized under the listed authorities. Failure to provide the requested information may be sufficient
cause for the U.S. Fish & Wildlife Service to deny the request.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary
to monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a permit is
requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information
requested in this form is purely voluntary. However, submission of requested information is required in order to process applications
for permits authorized under the above laws. 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. 1018-0022.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 1 hour 30 minutes
Amended submission - paper-based: 1 hour
Original submission - electronic: 1 hour 8 minutes
Amended submission - electronic: 45 minutes
These estimates include 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 form to this address.
FREEDOM OF INFORMATION ACT
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that
you identify any information that should be considered privileged and confidential business information to allow the Service to meet its
responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter
or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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