Form 3-200-67 Federal Fish and Wildlife Permit Application Form - Spec

FWS Form 3-200-67 (Rev. 01/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM
Special Canada Goose
(Migratory Bird Treaty Act; 50 CFR 21.26)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

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

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

TYPE OF REQUEST
New Application

NOTE: A Federal Special Canada goose permit is available only to State
wildlife agencies for certain resident (nonmigratory) Canada goose
management and control activities. If you are a landowner, homeowner’s
association, public land manager, or local government in the lower 48 states
Amendment
or the District of Columbia, you may register at this site for federal
If requesting a renewal or amendment, please provide authorization to destroy resident Canada goose nests and eggs on property
the permit #:
under your jurisdiction.

Renewal

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.f. Country

1.e. County/Province

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:
Yes
No
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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FWS Form 3-200-67 (Rev. 01/2020)
U.S. Department of the Interior

SPECIAL CANADA GOOSE PERMIT
(Migratory Bird Treaty Act; 50 CFR 21.26)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

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

SECTION E

1) A brief description of your state's long-term resident Canada Goose management concerns, including county, and
physical address, and latitude/longitude in decimal degrees (e.g. 36.87998/ -88.3435). For assistance determining the
latitude/longitude for a specific location in decimal degrees, please visit https://earthexplorer.usgs.gov/

2) An estimate of the size and trend of the resident Canada goose breeding population in your State and an explanation of
how the estimate was derived.

3) The number of resident Canada geese, including eggs and nests, that you propose to take annually.

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FWS Form 3-200-67 (Rev. 01/2020)
U.S. Department of the Interior

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

4) A detailed statement explaining how the goose management and control activities you propose will address human
health and safety concerns, protect personal property, or allow resolution of other injury to people or property. If your
State has a State Canada goose management plan, please attach a copy.

5) A statement indicating that the State will ensure that all employees and designated agents are fully informed
and briefed regarding the regulatory requirements and permit conditions.

6) The name and telephone number of the individual in your agency who will be in charge of the
Canada goose management activities authorized under your permit.

7) I acknowledge that I have read the form Instructions and FAQ, 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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FWS Form 3-200-67 (Rev. 01/2020)
U.S. Department of the Interior

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

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: 7 hours
Amended submission - paper-based: 5 hours
Original submission - electronic: 5 hours 30 minutes
Amended submission - electronic: 4 hours 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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