Form 3-200-65 Application - Registration of Appendix-I Commercial Bree

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

FWS Form 3-200-65 (Rev. 01/2020)
U.S. Department of the Interior

REGISTRATION OF APPENDIX-I COMMERCIAL BREEDING OPERATIONS (CITES)
☐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 3-200-65 (Rev. 01/2020)
U.S. Department of the Interior

E.

OMB Control No. 1018-0093
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REGISTRATION OF APPENDIX-I COMMERCIAL BREEDING OPERATIONS (CITES)

If you are applying for initial registration of an Appendix-I commercial breeding operation, complete section E. If
you are applying for renewal of an existing registration, complete section F.
Please respond to all questions in either section E or section F. Mark questions that are not applicable with “N/A”.
If needed, use a separate sheet of paper and indicate the number of the question you are addressing. If possible,
please also send your response electronically, which allows us to more easily forward the relevant materials to the
CITES Secretariat.
Electronic submission of inventories, photographs, and receipts/invoices: If you wish to provide information electronically,
please include a flash drive containing your information with your physical application.
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.

4. Name and address of the owner and manager of the captive-breeding operation.

5. Date of establishment.

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FWS Form 3-200-65 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
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6. Scientific name and common name of the Appendix-I species being bred.

7. Complete description of the parental breeding stock including:
a.

Total number and sex ratio of individuals that comprise the parental breeding stock.

b.

Age, sex, identification (such as band or tag numbers, transponders, or distinguishing marks), and origin
of parents (that is, wild-caught or captive-bred) of each specimen.

c.

Evidence of legal acquisition of each specimen, including receipts, CITES documents, capture permits,
etc.[Refer to Resolution Conf. 12.10 (Rev. CoP15)].

8. Current stock (number, by sex and age, of specimens held in addition to breeding stock).

9. Information on the percentage of mortalities experienced in the last 10 years and, where possible, on the
percentage mortalities in the different age groups and between males and females in the same time period.

10. Documentation showing that the species has been reliably bred to second generation offspring “F2” at the
operation and a description of the methods used.

11. If the operation has only bred the species to the first generation (F1), documentation showing that the
husbandry methods used are the same as, or similar to, those that have resulted in second-generation
offspring elsewhere.

12. Past (going back 10 years), current and expected annual production of offspring and, where possible,
information on:
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FWS Form 3-200-65 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0093
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a.

the number of females producing offspring each year; and

b.

unusual fluctuations in the annual production of offspring (including an explanation of the probable
cause).

13. An assessment of the anticipated need for, and source of, additional specimens to augment the breeding
stock to increase the genetic pool of the captive population in order to avoid any deleterious inbreeding.

14. Contingency measures for the safe disposal of captive stock in the event that the operation is closed.

15. Type of wildlife product you plan to export (such as live, skins, hides, other parts, or products).

16. Detailed description of the marking methods (e.g. bands, tags, transponders, branding) used for the
breeding stock and offspring and for the types of specimens to be exported (e.g. skins, meat, live animals).

17. Description of the inspection and monitoring procedures used by local, State, and/or Federal authorities to
confirm the identity of the breeding stock and offspring.

18. Description of the facilities to house the current and expected captive stock, including security measures
used by operation to prevent escapes and/or thefts. If applicable, please provide information on how
holding facilities are in compliance with local, State, and Federal regulations for housing, husbandry and
security of specimens. Detailed information should be provided on the number and size of breeding and
rearing enclosures, egg incubation capacity, food production or supply, availability of veterinary services
and record-keeping.

19. Description of the strategies used by the breeding operation, or other activities, that contribute to improving
the conservation status of wild population(s) of the species.

20. Assurance that the operation shall be carried out at all stages in a humane (non-cruel) manner (for
example, in accordance with local, State, or Federal governmental ordinances and/or guidelines developed
by professional societies or non-governmental organizations).

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FWS Form 3-200-65 (Rev. 01/2020)
U.S. Department of the Interior

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

F. RENEWAL OF EXISTING REGISTRATION (CITES):
21. CITES Registration number: ______________________________________
22. Name of the owner and manager of the captive-breeding operation.

23. Does your operation report to the FWS Migratory Bird Program (MBP)?

24. If yes, to which MBP office do you report?

25. In the last 5 years, have you added any new breeding stock that was not reported to the MBP? If yes,
please provide the following information:
a. Age, sex, identification (such as band or tag number, transponders, or distinguishing marks, and
origin (that is, wild-caught or captive-bred) of each new specimen.

b. Evidence of legal acquisition of each new specimen, including receipts, CITES documents,
capture permits, etc. [Refer to Resolution Conf. 12.10 (Rev. CoP15)].

26. In the last 5 years, has your annual production changed? If yes, please describe.

27. In the last 5 years, have you made changes to your breeding facilities? If yes, please describe.

28. Do you wish to export any products other than those noted in your original application for registration?

29. If yes, please provide a detailed description of the marking methods (e.g. bands, tags, transponders,
branding) used for the breeding stock and offspring and for the types of specimens to be exported (e.g.
skins, meat, live animals).

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FWS Form 3-200-65 (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:
Original submission - paper-based: 40 hours
Amended submission - paper-based: 20 hours
Original submission - electronic: 36 hours
Amended submission - electronic: 18 hours
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.

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