Form 3-200-41A Annual Report - Captive-Bred Wildlife Registration (CBW)

FWS Form 3-200-41a (Rev. 01/2020)
U.S. Department of the Interior

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

CAPTIVE-BRED WILDLIFE REGISTRATION (CBW) ANNUAL REPORT
☐New

☐Reissue/Renew ☐Amendment

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C.**
A. Complete if applying as an individual
1.a. Last name
2 Date of birth
(mm/dd/yyyy)

5.a. Telephone number

1.b. First name
5.b. Alternate telephone
number

1.c. Middle name or initial

1.d. Suffix

6. E-mail address

B. 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.a. Description of business, agency, Tribe, or institution

4.a. Principal officer (P.O.) last name 4.b. P.O. first name

4.c. P.O. middle initial

5. Primary contact name

6. Primary e-mail address

7.a. Business telephone number

7.b. Alternate phone no.

3.b. Website URL (if applicable)
4.b. P.O. Title

8.a. Primary contact telephone no.

C. 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. Include a check or money order, payable to the U.S. FISH AND WILDLIFE SERVICE, a nonrefundable processing fee (see the fee
schedule). Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the
processing fee – attach documentation of fee exempt status as outlined in instructions. (50 CFR 13.11(d))
2.
3.

If you are requesting a reissue/renew/amendment, what is your permit/file number?
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.

The individual/principal officer of the business must print and sign the application. (No photocopied or stamped signatures)

Date (mm/dd/yyyy)

** Click here for additional instructions on completing the above form (link to instruction page). See the last page for information on the Privacy Act,
Paperwork Reduction Act, Estimated Burden, and Freedom of Information Act aspects of this application form.
Mail your application(s) to Division of Management Authority, Branch of Permits, MS:IA 5275 Leesburg Pike, Falls Church, VA 22041-3803.
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FWS Form 3-200-41a (Rev. 01/2020)
U.S. Department of the Interior

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

Captive-Bred Wildlife Registration (CBW) Annual Report
Due: March 31st of the following year
Email to: [email protected] referencing “CBW Annual Report YYYY for CBW # MA#####” in subject line.
Permittee Name: ________________________________

Reporting Year: _____________

CBW Permit #: _____________

Complete this form (all three tables) for ALL live, non-native, ESA-listed species, captive-bred in the U.S., covered under your current CBW registration for
the above reporting year (including individuals you have on loan with another facility, or on loan with you). Do not include non-native ESA-listed species that
were not covered on your CBW permit during this year.
Year-end Inventory
Scientific Name
(Genus, species, and if
applicable,
subspecies)

EXAMPLE:
Loxodonta Africana

Common Name

Quantity

Sex/Age Ratio
(male.female.unknown
sex, 10.5.2)

# Births over the
reporting year

# Deaths over the
reporting year

Approx Death Date(s)
and Cause of
Death(s) (attach
necropsy report, as
needed)

African Elephant

17

10.5.2.

2

1

Aug 2019, old age

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

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FWS Form 3-200-41a (Rev. 01/2020)
U.S. Department of the Interior

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

Activities Conducted
CBW holder is required to disclose ALL interstate and intrastate purchases, sales, trades, and/or exports involving species listed under their CBW that
occurred during the reporting year.
Scientific
Name

Common
Name

Date of
Activity
(mm/dd/yy
yy)

EXAMPLE:
Loxodonta
Africana

Activity
(Interstate or
intrastate
purchases,
sales,
and/or
exports)

African
elephant

Interstate
purchase

04/12/201
9

Quantity &
Sex/Age
(males.females.
unknown sex,
10.8.3)

1.0.0

Name and Address of the other party
Involved in the transaction
(include country if an export)

Sunland Zoo and Park, 300 Leopard Way,
Miami, FL

CBW # of Registrant
Involved in Activity

Identification
Information
(e.g., studbook #’s,
microchip #’s, band
#s, etc.)

MA####

Studbook #: 152

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

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FWS Form 3-200-41a (Rev. 01/2020)
U.S. Department of the Interior

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

Loans/Gifts/Donations Conducted
CBW holder is required it disclose ALL loans, donations, and gifts involving species listed under their CBW that occurred during the reporting year.
Scientific
Name

Common
Name

EXAMPLE:
Loxodonta
Africana

African
elephant

Activity
(loans,
donations,
and gifts)

Date of
Activity
(mm/dd/yyyy)

Quantity &
Sex/Age
(males.females.unknown
sex, 10.8.3)

loan

4/12/2019

1.0.0

Name and Address of the other party
Involved in the transaction

Information on transferred Animal(s)
(studbook #’s, microchip #’s, band #’s,
tattoo #’s, etc.)

Sunland Zoo and Park, 300 Leopard
Way, Miami, FL

Studbook # 305
Tattoo yellow 6

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

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FWS Form 3-200-41a (Rev. 01/2020)
U.S. Department of the 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 (paperbased),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 form to this address.

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