Form 3-200-76 Application - Export of Caviar or Meat of Paddlefish or

FWS Form 3-200-76 (Rev. 01/2020)
U.S. Department of the Interior

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

EXPORT OF CAVIAR OR MEAT OF PADDLEFISH OR STURGEON REMOVED FROM THE
WILD (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 3-200-76 (Rev. 01/2020)
U.S. Department of the Interior

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

E. Export of Caviar or Meat of Paddlefish or Sturgeon Removed from the Wild (CITES)
NOTE: To ensure the most relevant application is being submitted, please review the following before completing this
form. To request export of live specimens removed from the wild submit form 3-200-27; export of aquacultured caviar or
meat submit form 3-200-80; export of aquacultured specimens submit form 3-200-24; re-export of specimens submit form
3-200-73; or export or re-export of species listed under the U.S. Endangered Species Act submit form 3-200-37.
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.
Complete all questions on the application. Mark questions that are not applicable with "N/A". If needed, use
separate sheets of paper. On all attachments or separate sheets you submit, indicate the application question
number you are addressing.
4. This application can be used to apply for:
_____ A single shipment for export. If approved, a single permit for a specific amount of caviar will be issued.
_____ Multiple shipments of identical amounts. For multiple shipments of identical amounts, the Service can
establish a master file. If the master file is approved, you can obtain a number of single-use permits, valid for 6
months each under 50 CFR 13.11.
To obtain single use permits from the master file, complete below:
i.

Total weight of caviar you are requesting to be authorized: ____________.

ii.

How many permits do you anticipate using in the next 6 months? _________. (Provide $5 for each 6month permit). Additional permits may be requested by submitting form 3-200-74.
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FWS Form 3-200-76 (Rev. 01/2020)
U.S. Department of the Interior

iii.

OMB Control No. 1018-0093
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Quantity and units you are requesting on each permit (must be identical for each permit):
(Example: Total Amount = 100 kg; 4 permits; 25 kg each.)

5. If requesting a single-use permit or master file with only one recipient, provide the name and address of
foreign recipient (if shipping to yourself, include your foreign address):
NOTE: Providing a foreign recipient is not required if establishing a master file.
Name:
Business Name:
Address:
Address:
City:
State/Province:
Country, Postal Code:

6. For each product to be exported, provide:
a.

Scientific name (genus, species, and if applicable, subspecies) and common name of the fish:

b.

State(s) and water body of harvest of source specimens, if not found on State harvest report:

c.

Product description (caviar or meat):

d.

Weight (in metric and standard units):

e.

Shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units):

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FWS Form 3-200-76 (Rev. 01/2020)
U.S. Department of the Interior

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

f.

Shipment will be fresh, frozen, pasteurized, or other (describe):

g.

If caviar, provide list of labels (see enclosed caviar labeling requirements).

h.

Current location of specimen(s):

7. Does this application request authorization to export a portion of a product(s) that was authorized under a
previous permit?
No. If no, continue to question 8.
Yes. If yes, complete a. below and continue to questions 8-13.
a. Provide a copy of the original CITES export permit and cleared 3-177 declaration form obtained when you
exported a portion of the previously authorized product, and complete and sign (in ink) the following
statement: I hereby certify that the product pertaining to this current application is a portion of product
previously authorized for export under permit number _______________________.
(fill in permit number)

Signature ____________________________________ Date _____________________
Questions 8 through 13 must be answered for the entire quantity of product(s) listed in your application. By signing this
application, you are certifying that all the information provided in support of this application is complete and accurate,
including any and all information provided about suppliers, dealers, and fishers.
8. List ALL intermediary suppliers’ and/or dealers’ names, addresses, State permit numbers, type of product
(i.e., meat or caviar), and weight of product obtained from each supplier (attach additional sheets of paper as
necessary):
Name:
Address:
City:
State/Province:
County, Postal Code:
State permit number:
Total weight of product supplied:
9. List ALL fishers’ full names and addresses, type of product, and weight of product obtained from each (attach
additional sheets of paper as necessary):
Name:
Address:
City:
State/Province:
County, Postal Code:
Total weight of product supplied:

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FWS Form 3-200-76 (Rev. 01/2020)
U.S. Department of the Interior

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

NOTE for questions 10-13: If you obtained product(s) from a supplier or dealer, you must supply all of the
following information from the supplier. All supporting documentation must be submitted in an organized format
to reduce processing time. We request that documentation is organized first by State of harvest (i.e., all
documentation for fish harvested from a particular state are grouped together). Within each State packet, the
documentation should be grouped by fisher (i.e., all invoices for a particular fisher are grouped together).
10. Provide a copy of the appropriate commercial buyer’s license(s).
11. For each fisher listed in number 9, provide a copy of the current license(s), permit(s), or other documents
issued by the State or local wildlife authorities approving the commercial fishing activities.
12. Provide copies of each fisher’s State harvest report for the product(s) to be exported. The harvest report
should include, at a minimum, the following information. If any of this information is not listed on the fisher’s
harvest report, the information must be provided separately for each fisher on an attached sheet of paper and
signed by the fisher.
a.

Dates the fish were harvested;

b.

Harvest location(s), including the State, county(ies), body of water, AND the nearest mile marker or
boat ramp to each harvest location; and

c.

Gear used to harvest the fish.

13. Provide copies of documentation showing the transfer of ownership (e.g., dated sales receipts/invoices) of the
product from each fisher or supplier to you. If you received the product from a supplier(s) or source other than
the harvesters, provide documentation demonstrating the history of transactions (chain of ownership of the
product) from the fisher(s) to you. You must be able to provide documentation for EACH change in ownership
from the time of harvest until the time you purchased the product.
All international shipment(s) must be through a designated port. A list of designated ports (where an
inspector is posted) is available. If you wish to use a port not listed, please contact the Office of Law
Enforcement for a Designated Port Exemption Permit (form 3-200-2).

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FWS Form 3-200-76 (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: 3 hours
Amended submission - paper-based: 2 hours 30 minutes
Original submission - electronic: 2 hours 30 minutes
Amended submission - electronic: 2 hours 15 minutes
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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