Form 3-200-40A Annual Report - ESA Museum Permit

FWS Form 3-200-40A (Rev. 01/2020)
U.S. Department of Interior

OMB Control No. 1018-0093
Expires ##/##/####

ESA Museum Permit Annual Report

Dear ESA Museum Permittee:
Enclosed is your new/renewed Endangered and Threatened Species Museum Permit. Please be sure to read all permit
conditions and use the ESA Museum permit correctly. Be aware that this permit only authorizes export and re-import of
preserved, frozen, dried, or embedded wildlife specimens or herbarium specimens currently accessioned in your
museum.
Reporting Requirements. On an annual basis, permittee must provide a report to the Division of Management
Authority that may be submitted as a spreadsheet as described in the below table. Copies of all validated Export/Reimport imports must also be submitted along with the annual report. If there is no activity to report, permittee must
provide a signed statement confirming that no export/re-import activities occurred during the year being
reported. If reports are not received annually, your permit may be subject to revocation.
Outgoing Specimen Report
Date Sent

Description of
specimen

Collection Date

Location where
obtained

Acquisition no.

Scientific name
and common
name

Receiving
institution,
Country

Collection Date

Location where
obtained

Acquisition no.

Scientific name
and common
name

Sending
institution,
Country

Incoming Specimen Report
Date Received

Description of
specimen

If you have additional questions, please contact the Division of Management Authority, Branch of Permits, MS: IA; 5275
Leesburg Pike, Falls Church, VA 22041-3803; phone (703) 358-2104 or fax 703 358-2281.
E-MAIL YOUR REPORT TO: [email protected] (Reference “ESA Museum Annual Report for
PRT #MA _______________” in Subject Line). Or mail to address on Permit.

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FWS Form 3-200-40A (Rev. 01/2020)
U.S. Department of Interior

OMB Control No. 1018-0093
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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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 which affect
protected species. This helps 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
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, under the applicable laws governing the requested activity, for which a permit is requested.
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 applicable 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. 1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages 20 minutes (electronically) to 30 minutes (paper-based),
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.

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