Form 3-200-49 Application - Approval, Amendment or Renewal of a Cooper

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

APPROVAL, AMENDMENT, OR RENEWAL OF A COOPERATIVE BREEDING PROGRAM
(Wild Bird Conservation Act)
☐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.
Page 1 of 9

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

E. Approval, Amendment, or Renewal of a Cooperative Breeding Program (Wild Bird
Conservation Act)
NOTE 1: This application must be approved before import permits can be issued for the purpose of cooperative
breeding. A Cooperative Breeding Program (CBP) must have at least two members. Zoological institutions
may be members of a CBP. Once a program is approved, you must submit application form 3-200-48 to
request import authorization for specific birds.
NOTE 2: The lead cooperator (as identified on page 1) for the breeding program must submit this
application.
Complete all relevant questions on the application. Mark questions that are not applicable with "N/A". Due to
the length of some questions, please use separate sheets of paper to answer the application questions. On all
attachments or separate sheets you are submitting; please indicate the number of the application question you
are addressing. If requesting authorization for more than one species or subspecies, please answer questions
5 – 10 for each species/subspecies.
Electronic submission of inventories, photographs, and receipts/invoices: If you wish to provide information
electronically, please include a flash drive containing this information with your physical application.
I want to:
___Establish a new cooperative breeding program (Please answer all questions)
___Amend an existing cooperative breeding program; CBP# __________
(If requesting new species, answers questions 4, 5, 6a, 6b, 6d, and 7; If requesting to add a member,
answer question 7)
___Renew an existing cooperative breeding program; CBP#___________
(If there are no changes to the membership or species in the CBP, please answer questions 11 and 12)
1. Name and address where you wish the permit to be mailed, if different from page 1. If you would like expedited
shipping, please enclose a self-addressed, pre-paid, computer-generated, courier service airway bill. If unspecified,
all documents will be mailed via regular mail through the U.S. Postal Service.

2. Who should we contact if we have questions about the application (name, phone number, and e-mail)?

3. Have you or any of the owners of the business (if applying as a business, corporation, or institution), been
assessed a civil penalty or convicted of any criminal provision of any statute or regulation relating to the
activity for which the application is filed; 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;
forfeited collateral; OR are currently under charges for any violation of the laws mentioned above?
No

Yes

If you answered “Yes” to Question 3, provide: a) the individual’s name; b) date of charge; c) charge(s); d)
location of incident; e) court, and f) action taken for each violation. Please be aware that a “Yes” response
does not automatically disqualify you from getting a permit.

Page 2 of 9

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

4. A description of the species/subspecies to be covered (imported) under the program, including:
a. Scientific name (genus, species, and, if applicable, subspecies) and common name;

b. Number of birds requested to meet the goals of the program (Note: indicate the total number of birds
to be imported by all the members of the CBP for the life of the program);

c.

The minimum number of participating facilities need to achieve management objectives – provide an
explanation of how this number was derived; and

d. Desired sex ratio.

5. A statement justifying the need for this approval, which includes information on the current U.S. captive
population of the requested species/subspecies and the need for import of additional specimens. Information
should include, if applicable, whether there is high trade of the species; it is being captive-bred from reintroduction purposes; you are collaborating with other groups to promote in-situ conservation and the
sustainability of the species in the long-term.

a. Provide a description of the cooperative breeding program that includes: Managing genetic diversity
is an important component to creating a long-term sustainable captive population. What scientifically
grounded method(s) does the CBP intend to use to measure both projected and current levels of
genetic diversity within the population? For projected gene diversity, what is the time frame that will
be considered (for example, projected gene diversity at 100 years of 10 generations);

b. Description of the long-term plans for developing and maintaining a self-sustaining population in
captivity of the exotic bird species;

c.

Details on the system of record keeping and tracking of birds and their offspring, including how
individual specimens will be marked or otherwise identified;

Page 3 of 9

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

d. Explanation on the relationship of the cooperative breeding program to the conservation of the exotic
bird species in the wild. Include information on whether you anticipate importing captive bred birds or
wild caught birds and include identified sources to ensure that the number of birds that you anticipate
needing will be available;

e. Information on the long-term funding of the cooperative breeding program to ensure its existence until
the CPB’s breeding goals are met; and

f.

Detailed plans for the placement of the program birds and any offspring, recalling that birds
imported as part of a cooperative breeding program cannot be loaned, sold or otherwise
transferred to a non-member without prior authorization of this office. Also, provide a
description of how program birds will be dealt with if a member(s) leaves the program or if the
program is voluntary terminated (members decide to disband and the program is not renewed) or
involuntary terminated (the Service does not renew the CBP).

6. Describe care and maintenance of the requested species/subspecies, and how each prospective member’s
facilities meet professionally recognized standards, including (if requesting to amend an established CBP by
adding new members, please provide the following for each proposed new member):
a. Name and addresses of each facility where the birds, by species, will be maintained;

Page 4 of 9

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

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

b. In the table below, please provide the requested information for each type of holding space that will be used to house CBP birds. Use one row for each holding
space type (flight cages with different dimensions should be listed on separate rows as should indoor vs. outdoor aviaries).
1. CBP
member,
facility name
EXAMPLE

Rev. 08/2017

2. Aviary type (outdoor
vs. indoor flight cage,
etc.). Add a separate
row for type of aviary.

3. Dimensions of specific
aviary/holding space (WxLxH).
Please specify units (feet,
inches, etc.)

4. How many
aviaries fit these
specifications?

5. What species will
be housed in this
type of aviary?

6. How many birds will be
housed in each of the
aviaries?

8. Will the birds be housed here permanently? If
not, please provide additional information in the
comments box below (i.e. why will the birds be
moved and for how long).

Outdoor flight

10’x10’x8’

4

Amazona
ochrocephala

Up to 4 birds in two of the
flight cages. The two
remaining flight cages will be
vacant for future imports.

These cages will be used to socialize young birds
or for surplus birds

Outdoor flight

8’x5’x7’

2

Amazona
ochrocephala

2

These will be permanent breeding cages and the
birds will remain here for multiple breeding
seasons. If these birds are transferred we will
include that information in our CBP annual report.

Page 5 of 7

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

c.

For each type of aviary listed above, please provide a photo with a caption indicating the ‘type’ as listed in column

d.

Please provide information on where any progeny will be housed.

e.

Please provide husbandry practices specific to each species as necessary.

f.

A qualification statement for EACH individual who will be participating in CBP. This statement should
include records showing the participant's prior breeding experience with bird species that are the same or
similar to the species in the CBP.

7. Each CBP must identify an appropriate avicultural, zoological, or conservation organization that has agreed
to oversee its activities. Please provide a statement from the designated oversight organization, on the
organization’s letterhead, that includes at a minimum:
a. Description of the expertise of the organization to serve as an oversight organization;

b. Criteria for acceptance of individuals into the proposed breeding program;

Page 6 of 9

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

c.

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

How participation in the program will be monitored; and

d. Relationship of the oversight organization to the CBP in establishing and maintaining a selfsustaining captive population of the exotic bird species or enhancing the conservation of the
species in the wild.

8. If you are amending or renewing a program, you must also provide the following information in a table
format:
a. The number, species, and sex of all birds that have been imported to date for your CBP, including
dates of import, countries of origin, disposition of the imported birds for each importer, and
associated permit numbers for each permit. Identify the number of birds within each species and
their sex held at each facility;

b. For each program participant, a summary of any breeding activity that has been achieved with the
imported birds, including the number of eggs and progeny produced, and the disposition of any
progeny;

c.

For each program participant, a summary of any mortality, including mortality during transit or
quarantine (for birds that died in quarantine, you must provide appropriate documentation from
USDA/Veterinary Services) of birds imported as part of the approved cooperative breeding
program, as well as details of any post-fledging mortality of their progeny;

Page 7 of 9

FWS Form 3-200-49 (Rev. 01/2020)
U.S. Department of the Interior

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

d. A summary of progress made towards achieving a self-sustaining captive population of each
species;

e. An explanation of any substantive changes that have or will occur regarding any aspect of the
approved cooperative breeding program; and

f.

An official letterhead statement from the designated oversight organization approving the
amendment or renewal.

9. Provide a signed and dated statement from each CBP member. The statements must contain the following
information:
a. Member name;

b. Scientific name of all species being requested for the program;

c.

Statement that the member is aware of the purposes of the cooperative breeding program and the
Wild Bird Conservation Act and will abide by the regulations and conditions placed on the program,
if it is approved.

Page 8 of 9

FWS Form 3-200-49 (Rev. 11/2019)
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 2 hours 30 minutes (electronically) to 3 hours
(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 form to this
address.

Page 9 of 9