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pdfFWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
EXPORT OF FERTILIZED LIVE EGGS, CAVIAR OR MEAT FROM AQUACULTURED
PADDLEFISH OR STURGEON (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.
Page 1 of 7
FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
E. Export of Fertilized Live Eggs, Caviar or Meat from Aquacultured Paddlefish or Sturgeon (CITES)
NOTE: To request export of species listed under the U.S. Endangered Species Act, submit form 3-200-37.
Review this application carefully and provide complete answers to all of the questions in the sections relevant
to the activity for which you are requesting authorization. If a question is not applicable, answer with "N/A".
On all attachments or separate sheets you submit, indicate the application question number you are addressing.
If requesting authorization for more than one species, please make sure that you respond to each appropriate
question for each species.
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.
This application can be used to:
☐ Request a single-use permit for export of a specific amount of caviar that is valid for 6 months from the
date of issuance. For re-issuance or amendment of a single use permit, the original permit must be returned with
this completed application form.
☐
Establish a Master File: A “Master File” can authorize exports of specific amounts of caviar and can be
valid for up to 3 years from the date of issuance. Once the Master File is approved, you must obtain partially
completed certificates to export. Partially completed certificates are $5 each and are valid for 6 months.
Certificates must be obtained prior to making any shipment and must accompany the shipment.
☐
Amend an existing Master File: A “Master File” must be amended when there have been any changes to
the information provided in the original application for a master file. You need only provide the requested
information for the changes that need have occurred. However, if you intend to renew your current Master File at
the same time you are amending it, see below.
☐
Renew (or Amend and Renew) a Master File: To renew a Master File that has or will soon expire, you
must complete this entire application, including providing all of the information requested in this form for all
specimens to be included in your Master File and information on any changes to your facility, operations, species,
or suppliers for the specimens that you wish to export.
For either the establishment of a new master file or renewal/amendment of an existing master file, please
indicate the number of single-use permits you anticipate using in the next 6 months _____________
(Provide $5 for each 6-month permit.) Additional permits may be requested by submitting form 3-200-74
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)?
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FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
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. 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:
5. For each species from which product will be exported, provide:
a.
Scientific name (genus, species, and if applicable, subspecies) and common name of the fish.
b.
State(s) of source specimens.
c.
Address where the facility(s) is located.
d.
Product description (e.g., fertilized live eggs, caviar, or meat).
e.
Weight to be exported (metric and standard units).
f.
Description of shipping containers to be used (e.g., jars, tins, buckets) and sizes (provide units).
g.
Will shipment be fresh, frozen, or pasteurized, or other (describe).
h.
Current location of specimen(s).
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FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
6. For each facility, provide:
a.
Photos and a description.
b.
Number of years the facility has maintained the requested species.
c.
Provide a copy of the appropriate state, Federal license(s) for the facility.
7. Provide the following regarding your production estimates for each species being requested and each facility
identified above:
a.
Number of brood stock spawned annually.
b.
Estimated total weight of eggs produced annually.
c.
Average annual growth rate of fish achieved at the facility.
d.
Biomass, by age class and sex, at the beginning of the year; remaining biomass, by age class and
sex, at the end of the year.
e.
Total live stock sold by age class and sex.
f.
Total “green” roe harvested annually (by weight).
g.
Total amount roe determined not to be fit for processing and discarded (by weight).
h.
Total caviar sold domestically (by weight).
i.
Total caviar sold internationally (by weight).
j.
Estimated number of fry produced annually.
k.
Total meat production.
l.
Total meat sold domestically by sex (live weight is acceptable).
m.
Total meat sold internationally by sex (live weight is acceptable).
n.
Mortality rates by age class.
o.
Information regarding disease outbreaks, this information should include the causative agent, if
known, percent mortality, relevant pathological findings, and plan to reduce future disease outbreaks.
p.
Sacrifice rates by age class and sex.
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FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
8. Provide a statement on how your captive population(s) is being managed to maintain genetic viability.
9. Do you supplement from the wild?
No
Yes
If yes,
a.
Provide a copy of the state authorization or collection permit(s) (i.e., aquaculture permit,
broodstock permits, and capture logs).
b.
What is the disposition of wild-origin fish (males and females) once they have been used to
improve the genetic viability of your farm-raised population?
c.
When is the last time you supplemented your stock with wild-origin fish?
d.
When do you next intend to use wild-origin fish to improve the genetic viability of the population?
10. Provide production records for the previous year.
11. Are all roe that you are exporting F2 generation or more?
12. If you are the Breeder, sign (in ink) the following statement:
I hereby certify that the species listed above to be exported were bred and born/hatched from parental stock
at my facility listed below.
Name and address of your facility where the animals were bred and born;
Current location of parental stock:
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FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
OMB Control No. 1018-0093
Expires ##/##/####
Signature and date ____________________________________________________________
If you obtained stock from another facility, provide copies of documentation showing that you acquired the
specimens from the breeder or documentation demonstrating the history of transactions (chain of ownership
of each specimen) and a signed statement from the breeder or breeder's record that includes:
a.
Complete name and address of the breeder's facility.
b.
Scientific and common name of the species.
c.
Statement that the specimen(s) was/were bred and born/hatched at his/her facility.
d.
Birth/hatch date, and if applicable band/tag number, or other identifiers.
e.
Location (Name, Street address, City, State) of Parental Stock.
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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OMB Control No. 1018-0093
Expires ##/##/####
FWS Form 3-200-80 (Rev. 01/2020)
U.S. Department of Interior
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 45 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.
Page 7 of 7
| File Type | application/pdf |
| File Title | NPS Form 10-29 |
| Author | dhaas |
| File Modified | 2020-03-09 |
| File Created | 2020-01-28 |