Form 3-200-39A Annual Report - Certificate of Scientific Exchange (COSE

FWS Form 3-200-39A (Rev. 01/2020)
U.S. Department of Interior

CERTIFICATE OF SCIENTIFIC EXCHANGE (COSE)
SPECIAL REPORTING CONDITIONS

Permit #:

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

(ex. 17US123456/9)

Permittee:_______________________________________________________________________
Reporting Requirements: Annually, permittee must provide a report to the Division of Management Authority,
Branch of Permits, MS: IA; 5275 Leesburg Pike; Falls Church, VA 22041-3803 or e-mail report to
[email protected]. This report must describe all exchanges of specimens that occurred in the preceding calendar
year and made under the registered scientific institution system under the COSE [CITES Resolution Conf. 11.15
(Rev. CoP12)]. A suggested format is described below. Non-activity must also be reported. If reports are not
received annually, the CITES registration is subject to revocation.

Outgoing Specimen Report
Date Sent

Description of
specimen

Accession or
Record no.

Scientific name
and common
name

Receiving
institution,
Country

COSE Code No.

Accession or
Record no.

Scientific name
and common
name

Originating
institution,
Country

COSE Code No.

Incoming Specimen Report
Date Received

Description of
specimen

In addition, permittee must maintain complete and accurate records of any specimens imported or exported under
this Certificate (50 CFR 13.46). The records must be kept current and should include the name, address, and
COSE number of the institution sending or receiving specimen(s), a description of the specimen(s) exchanged,
and the date the exchange occurred. The records must be maintained for five years from the date of expiration of
the Certificate. The permittee must make the records available to US Fish and Wildlife Service employees for
inspection upon request.
E-MAIL YOUR REPORT TO: [email protected] (Reference “COSE Annual Report for PRT #
on the Subject Line). Or mail to address on the Permit.

”

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FWS Form 3-200-39A (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 24 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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