Federal Permit Application for Annual Dealer Permit

Instructions for the Federal Permit Application for Annual Dealer
Permit
Rev 05/11/2020
In addition to the instructions provided herein, applicants with specific questions are encouraged to contact the
Permits Office at (727) 824-5326 or toll free at (877) 376-4877 between 9:00 a.m. and 4:00 p.m. ET, or visit
the SERO Permits website at https://www.fisheries.noaa.gov/permits-and-forms.

Please consult the U.S. Code of Federal Regulations whose guidance for application requirements, permit
eligibilities, and related information will always prevail. NMFS will return incomplete or illegible applications.

General Instructions:
What Sections do I complete?
Complete all applicable sections of this application form. All application fields should be typed or printed in ink.
Specifically,
All applicants must fill out Section 1, 2, and 3.
If the dealership, as listed in Section 1 and on the applicable state wholesale licenses, is a business
that is owned by another business, fill out Section 4.
If the dealership, as listed in Section 1, is a business, fill out Section 5 for all individual owners of the
dealership listed in Section 1.
Also, complete Section 5 for all individual owners of businesses that own dealership, as listed in Section
4. Copy Sections 4 and 5 as necessary to provide information for all owners of the dealership, and
owners of businesses that own the dealership.
All applicants must fill out Sections 6 and 7.
See pages 2-4 for information about specific sections of this application.
What is the fee?
The application fee is $50 for one fishery and $12.50 for each additional fishery, as described in the table
below. This application fee is collected to cover the administrative cost of processing the application, and is nonrefundable.
The fee to replace one or more permits issued to a dealer is $18. NMFS will not refund money for denied
permits. A check or money order payable to the U.S. TREASURY must accompany each application.
Permits 1 = $50

2 = $62.50

3 = $75

Where do I send the application?
Mail the complete application, payment, and all required supporting documentation to:
NMFS Permits Office (F/SER14)
263 13th Avenue South,
St. Petersburg, FL 33701
To receive permits via overnight carrier, enclose a completed, pre-paid air bill and envelope. Please note using
the prepaid overnight delivery option does not expedite permit processing; it only expedites delivery of your
completed permit package.

1

What about reporting compliance?

All dealers are required to report purchases electronically. Not all electronic reporting programs can
run on all operating systems or platforms. New dealers are encouraged to reach out to the
appropriate State and Federal Agencies before obtaining a dealer permit to check on operating
system compatibility and other requirements. NMFS will not renew a dealer permit until all reporting
requirements for the permit being renewed have been met (e.g., SAFIS, Trip Ticket, HMS electronic
dealer reporting, e-1 Ticket, PC-1 Ticket programs). To avoid delays, applicants are encouraged to
comply with all reporting requirements before submitting a permit application.
• Communications concerning Atlantic shark and/or swordfish dealer reporting requirements must be directed
to the Atlantic Highly Migratory Species (HMS) Management Division at (301) 427-8590
• Communications concerning Gulf and South Atlantic Dealer (GSAD) reporting requirements must be directed

to the SEFSC Quota Monitoring Office at (305) 361-4581. Current reporting status can be viewed
at https://grunt.sefsc.noaa.gov/drsr/

What supporting documentation do I need?
State Wholesale License: Provide a copy of the valid state whole sale license for each state in which the
dealership has a facility
Payment: Include a check or money order made out to the US Treasury. See “What is the Fee” on page 1
of these instructions for more information.
HMS Workshop Certificate: Shark dealers must provide a copy of one of the following HMS Workshop
Certificates:
(A) Valid Dealer Certificate,
(B) Valid Proxy Certificate from an employee of the dealership, or
(C) If the dealer’s has an expired shark dealer permit, or if the dealer has never been issued a shark dealer
permit, a General Participant Certificate from an officer or owner of the dealership will also be accepted.
APPLICATION SECTION 1 –DEALER INFORMATION.
Complete all applicable portions of Section 1.
In Section 1A
• Enter the dealership name as it appears on the state wholesale license(s). If the dealership uses a fictitious
name, or does business as another name, provide the DBA name in the space provided. All dealerships must
provide a valid email address, and telephone number.
• If the dealership is a business, provide the dealership’s Federal Employer Tax Identification Number (FEIN) and
date the dealership was formed.
• For a brief definition of applicable business types, see our frequently asked questions at
http://sero.nmfs.noaa.gov/operations_management_information_services/constituency_services_branch/permits/
permit_faq/index.html
• If the dealership is an individual, provide the dealer’s Individual Tax ID Number (SSN) and date of birth.
In Section 1B
• Provide a mailing and physical address for the dealership in Section 1b.

APPLICATION SECTION 2 – Permits Requested.
Indicate the fishery and transaction type of the permits requested.

2

APPLICATION SECTION 3 – Receiving Facilities.
Provide information for each physical address where fish are received. The “physical facility” must
be the dealer’s brick and mortar facility. If the facility listed is a marina, boat ramp, dock, or other
location where the boat unloads, than the dealer must own or leases the marina, boat ramp, dock,
or other place. Public docks and boat ramps may not be considered a dealer facility.
Include a copy of the state wholesale license from each state in which the dealer has a facility.
Company B

Company A

APPLICATION SECTION 4 –Businesses that Own Businesses
Complete this section for any business that owns more than 1% of any business within the
ownership hierarchy of the dealership.
For every business, the sum of ownership, by either individuals or other businesses, must total 100%.
Photocopy this section as necessary to provide information about all businesses within the
ownership hierarchy of the dealer.

• For each business, provide the business’s full name, Federal Employer Tax ID number (FEIN),
date the business was formed, phone number, physical and mailing address, and business type.
• Indicate if the business was established by the laws of the United States or any state of the
United
States. Note, this information will not affect eligibility to obtain a permit.
• Provide an email address or SMS mobile phone number to receive digital updates about your permit and
application status (when available).
• For a brief definition of applicable business types, see our frequently asked questions at
http://sero.nmfs.noaa.gov/operations_management_information_services/constituency_services_branch/permits/
permit_faq/index.html
•
Example: If the dealer, as identified by the state wholesale license(s), is owned by Company A, provide
information about Company A in Section 4. If Company B owns Company A, also provide information about
Company B in section 4.

APPLICATION SECTION 5 – Businesses Officers and Individual Owners
Complete this section for any individual that owns more than 1% of any business within the ownership
hierarchy of the dealership, as listed in section 1 and 4. For every business, the sum of ownership, by
either individuals or other businesses, must total 100%. Photocopy this section as necessary to
provide information about all businesses within the ownership hierarchy of the vessel
• For each individual owner or officer, include the entity’s full name, Individual Tax ID number (SSN), date of birth,
phone number, physical address, mailing address, sex, and race/ethnicity information.
• Indicate if the individual is a United States citizen or permanent resident alien. Note, this information will not
affect eligibility to obtain a permit.
• Provide an email address or SMS mobile phone number to receive digital updates about your permit and
application status (when available).
• Minor shareholders: Complete Section 5b if a business listed in Section 1, or 4 has owners that individually own
less than 1% of the business. Provide the total percentage of ownership which is individually held by owners who
own less than 1%. This section is left blank for most applicants.
Example: If the dealership is owned by Company A, provide information about all owners and officers of
Company A. If Company A is also owned in whole or part by Company B, complete section 5 to provide
information about all individual owners and officers of Company A and Company B.
Photocopy this section as necessary to provide information about all businesses and their respective owners and
officers that comprise the ownership hierarchy of the vessel.

3

APPLICATION SECTION 6 – Small Business or Organization Certification
This section is required for ALL applicants. Your revenue and employment estimates for the most recent complete
calendar year your business or organization was active should include the revenues and employees of ALL affiliated
businesses or organizations. In general, businesses or organizations are affiliated with each other when one
business or organization controls or has the power to control another business or organization, or a third party
controls or has the power to control both. Specifically, businesses or organizations are considered to be affiliated if
they have 50% or more ownership in common. For e.g., if the same individual or individuals own or co-own multiple
businesses, those businesses would be considered affiliated and thus should be treated as a single operation for the
purpose of estimating annual gross revenues and employment.

APPLICATION SECTION 7 – SIGNATURE FOR APPLICATION
The applicant must sign the application in section 7. If the dealership is a business, the signee must be an
officer or owner of the dealership business.

KNOWINGLY SUPPLYING FALSE INFORMATION OR WILLFULLY OVERVALUING ANY FISHING INCOME TO OBTAIN A
PERMIT IS A VIOLATION OF FEDERAL LAW PUNISHABLE BY A FINE AND/OR IMPRISONMENT.
Public Burden Statement - A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to
a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the
information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0205.
Without this approval, we could not conduct this survey or information collection. Public reporting for this information collection is estimated to be
approximately 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the information collection. All responses to this information collection are required to obtain benefits.
Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to
the: PRA Officer, National Marine Fisheries Service, F/SER26, 263 13th Avenue South, St. Petersburg, FL 33701.
Privacy Act Statement - Authority: The collection of this information is authorized under the Magnuson-Stevens Fishery Conservation and
Management Act (16 U.S.C 1801 et seq.), the High Seas Fishing Compliance Act, the Tuna Conventions Act of 1950, the Antarctic Marine Living
Resources Convention Act, the Western and Central Pacific Fisheries Convention Implementation Act (16 U.S.C. 6901 et seq.), the Marine Mammal
Protection Act, the Endangered Species Act and the Fur Seal Act. The authority for the mandatory collection of the Tax Identification Number (TIN) is
31 U.S.C. 7701.
Purpose: In order to manage U.S. fisheries, the National Marine Fisheries Service (NMFS) requires the use of permits or registrations by participants
in the United States. Information on NMFS permit applicants and renewing holders includes vessel owner contact information, date of birth, TIN and
vessel descriptive information. Permit holder information may be used as sampling frames for surveys, as part of Fishery Management Council (FMC)
analysis to support FMC decisions.
Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure of this information
is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within NMFS offices, in order to coordinate monitoring and
management of sustainability of fisheries and protected resources, as well as with the applicable state or regional marine fisheries commissions and
international organizations. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of
Records Notice COMMERCE/NOAA-19, Permits and Registrations for the United States Federally Regulated Fisheries.
Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of
eligibility for a permit.

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OMB Control No. 0648-0205; Expiration date: 05/31/2020

U.S. Department of Commerce, NOAA
NMFS PERMITS OFFICE, F/SER14
263 13th Avenue South
St. Petersburg, FL 33701
Toll Free 877-376-4877 (9:00 a.m. - 4:00 p.m. ET)
727-824-5326 (9:00 a.m. - 4:00 p.m. ET)
https://www.fisheries.noaa.gov/permits-and-forms

FEDERAL PERMIT APPLICATION FOR
AN ANNUAL DEALER PERMIT
FOR OFFICE USE ONLY
Reviewer’s Initials and Date
Check or Money Order Number
and Amount
SERO Dealer Number
Non Compliance Hold Date
Non Compliance Cleared Date
Expiration Date

FOR OFFICE USE ONLY

SCAN DATE AND INITIALS

Application ID
Include a copy of the State Wholesale/Dealer license for each state where product will be first received from the commercial fisherman/vessel. The name shown on your
State Wholesale License(s) and your Federal Dealer permit must match in ownership. Please provide the name below as it appears on the State Wholesale License. The date
formed refers to the date in which the corporation or business was formed (the date the business was filed for with the Secretary of State in the state where the business was
formed). The FEIN is the number that was provided to you by the IRS (if applicable).

SECTION 1 - DEALER INFORMATION (PERMIT HOLDER)
Provide the name below as it appears on the state wholesale or dealer license.

Yes

Do you use a DBA
name?

1a. Dealer’s Name as it appears
on the State Wholesale License
Area Code

If yes, What is the DBA name?

Phone Number

No

E-Mail Address (REQUIRED—See Instructions)
This Email Address is the same one you will use for reporting purposes.

If the dealer is a Business:
Dealer is
(check one):

C Corporation

Federal Employer Tax ID Number (FEIN)

Partnership

Limited Liability Co.

Date Business Formed (MM/DD/YYYY)

Cooperative

Other _____________

Was this Business properly established by
the laws of the United States or any state
of the United States?

Is this individual a United States Citizen
or permanent resident alien?

If the dealer is an Individual:

Is this Individual of Hispanic, Latino, or Spanish origin?
What is this
individual’s
race?

S Corporation

Yes

No

What is this
individual’s Sex?

YES

YES

Male

NO

Female

White

American Indian or Alaska
Native

Native Hawaiian or Other Pacific Islander

Black or African American

Asian American

Other _______________

Last Name

Middle Name

First Name

Individual Tax ID Number (SSN)

Suffix - Jr, Sr, etc.

Date of Birth (MM/DD/YYYY)

1.b. REQUIRED—Address Information for either Business Or Individual Dealer:
Mailing Address

Apt #

City

State

County/Parish

Zip Code

Country

State

County/Parish

Zip Code

Country

Check box if the Physical Address is the same as the mailing address—OR:
Physical Address (PO Box not acceptable)

Apt #

City

1

D2020.1P - Form Revision 05/11/2020

NO

SECTION 2 - PERMITS
Indicate which permit(s) you are applying for by checking the box adjacent to the corresponding fishery. Also indicate if this is a new or renewal
of a permit.
NEW

RENEW

FEE SCHEDULE

Gulf of Mexico and South Atlantic Dealer (GSAD)

1 Permit = $50.00

Domestic Atlantic Swordfish (SD)
(Includes the Gulf of Mexico and the U.S. Caribbean)

2 Permits = $62.50

Atlantic Shark (SK)
(Includes the Gulf of Mexico and U.S. Caribbean)

3 permits = $75.00

Applicants for an Atlantic Shark Dealer permit must provide a copy of the unexpired Shark Identification Workshop Certificate for each facility listed below OR have a copy of the unexpired certificate on file with the permits office at the time of

SECTION 3 - RECEIVING FACILITIES
List the names and physical addresses for facilities where product is received (fish is off loaded from the fishing vessels directly to the permit holder shown in section 1). You
do not need to list facilities where product is received then shipped to the permit holder. Please copy this page as needed to provide information on all facilities where fish
are directly offloaded to the permit holder. If you receive product in different states, you must provide a copy of your valid State Wholesale License for each state.

Check here if a location where you receive product directly from fishermen is the same as the physical address shown in
section 1b. If checked, you do not need to re-list that location here.
1. Facility Name

Physical Address (PO Box not acceptable)

Area Code

Apt #

City

State

2. Facility Name

Physical Address (PO Box not acceptable)

City

State

Apt #

City

State

4. Facility Name

Physical Address (PO Box not acceptable)

Apt #

City

State

Physical Address (PO Box not acceptable)

Apt #

City

State

Physical Address (PO Box not acceptable)

Apt #

City

State

2

Country

Zip Code

Country

Zip Code

Country

Phone Number

County/Parish

Area Code

6. Facility Name

Zip Code

Phone Number

County/Parish

Area Code

5. Facility Name

Country

Phone Number

County/Parish

Area Code

Zip Code

Phone Number

County/Parish

Area Code

3. Facility Name

Physical Address (PO Box not acceptable)

County/Parish

Area Code

Apt #

Phone Number

Zip Code

Country

Phone Number

County/Parish

Zip Code

Country

SECTION 4 - BUSINESSES THAT OWN THE DEALER
Complete this section for each business that owns 1% or more of the dealer shown in section 1. Copy this section as needed.

Section 4a: Business owner:
Business for which this business is an owner of:
Percent of Business Owned:
Type of
business:

S Corporation

Cooperative

Other_______________

C Corporation

Limited Liability Co.

Partnership

Was this Business properly established by
the laws of the United States or any state
of the United States?

YES
NO

Registered Name of Business

Federal Employer Tax ID Number (FEIN)

Date Business Formed (MM/DD/YYYY)

Mailing Address

Apt #

City

Area Code

Phone Number

State

County/Parish Zip Code

Country

State

County/Parish Zip Code

Country

Check box if the Physical Address is the same as the mailing address, OR:
Physical Address (PO Box not acceptable)

Apt #

City

OPTIONAL: Check here if you would you like to receive digital updates (texts & emails). Provide your digital contact information belo w.

Cell Phone number and provider:

Email
Section 4b: Additional Business owner:
Business for which this business is an owner of:
Percent of Business Owned:
Type of
business:

S Corporation

Cooperative

Other_______________

C Corporation

Limited Liability Co.

Partnership

Was this Business properly established by
the laws of the United States or any state
of the United States?

Registered Name of Business

Federal employer Tax ID Number (FEIN)

Mailing Address

Date Business Formed (MM/DD/YYYY)

Apt #

City

Area Code

Phone Number

State

County/Parish

Zip Code

Country

State

County/Parish Zip Code

Country

Check box if the Physical Address is the same as the mailing address, OR:
Physical Address (PO Box not acceptable)

Apt #

City

OPTIONAL: Check here if you would you like to receive digital updates (texts & emails). Provide your digital contact information belo w.

Email

Cell Phone number and provider:

3

YES
NO

SECTION 5 - BUSINESS OFFICERS AND INDIVIDUAL OWNERS (Cont.)
Complete this section by providing information on all individual officers and owners that own 1% or more of any business listed in section 1 (the dealer) and/or
section 4 (businesses that own the dealer).

Copy this page as needed to provide information on ALL other officers or shareholders
that own 1% or more of the business. The ownership must total 100%

Section 5a: Individual Officer/Owner:
Business for which this individual is an officer/owner of:
Position Held - Check ALL That Apply
Vice President
President/CEO
Percent of Business Owned:

Secretary

White
Black or African American

Last Name

Individual Tax ID Number (SSN)

Mailing Address

Director/ Manager

Shareholder

Other
YES

Is this individual a United States citizen or permanent resident

Is this Individual of Hispanic, Latino, or Spanish origin?
What is this
individual’s
race?

Treasurer

No

Yes

What is this
individual’s Sex?

American Indian or Alaska
Native

Female

Native Hawaiian or Other Pacific Islander
Other _______________

Asian American

Middle Name

First Name

Date of Birth (MM/DD/YYYY)

Apt #

Male

NO

City

Area Code

Suffix - Jr, Sr, etc.

Phone Number

State

County/Parish

Zip Code

Country

State

County/Parish Zip Code

Country

Check box if the Physical Address is the same as the mailing address, OR:
Physical Address (PO Box not acceptable)

Apt #

City

OPTIONAL: Check here if you would you like to receive digital updates (texts & emails). Provide your digital contact information belo w.

Email

Cell Phone number and provider:

Section 5b: Minor Shareholders: Complete this section by providing information on all individual officers and owners that own less than
1% of any business listed in section 1 (the dealer) and/or section 4 (businesses that own the dealer).

MINOR OWNERS - Check here if one or more owners (individual OR business) holds shares that are less than 1% of the total business shares.
TOTAL PERCENTAGE of the business shares held by minor owners.

4

SECTION 6 - SMALL BUSINESS OR ORGANIZATION CERTIFICATION
ALL applicants must complete this section
● For vessels that are leased, complete this section for business(es), including sole proprietorship(s),or organization(s) that
lease the vessel.
● For vessels that are not leased, complete this section for business(es), including sole proprietorship(s), ororganization(s)
that own the vessel (i.e., the business(es), including sole proprietorship(s), or organization(s) that appear on the vessel’s
USCG documentation or state registration).
Information needed to complete this section: Please estimate your annual gross revenues (sales) for the most recent calendar
year your business or organization was active prior to this year. Your primary activity is the activity that generated the greatest
percentage of annual gross revenues in the most recent complete calendar year the business or organization was active. Review
the business/organization descriptions in Boxes 1 through 7 and identify the one that describes the applicant’s primary activity. If
the business is primarily a seafood dealer or processor, estimate the number of employees for the most recent calendar year your
business or organization was active prior to this year. Include all full-time, part-time, and temporary employees in your estimate,
but do not include crew that work on any vessels owned by the business or organization or its affiliates. Your estimates should account for the revenues and employees of ALL businesses and organizations with which your business or organization is affiliated.
See the instructions at the beginning of the application package for more information about affiliation. If you have questions about
affiliation and how it applies in your case, please call 727-824-5305 and ask for one of our Office’s economists.
How to fill out the form: Start with Box 1. If the answer to the question in Box 1 is “Yes,’’ check “Yes” and answer the questions in
the box to the right and follow the instructions in that box. If the answer to Question 1 is “No,” check “No” and go to Box 2. Continue this process until you have either: (1) answered “Yes” to ONE of the questions in Boxes 1 through 6 AND the applicable questions in the boxes to the right, OR (2) answered all questions in Box 7.
Box 1. Is the business primarily involved in
harvesting seafood (commercial fishing)?

1A) Was the business active prior to
this year?

Yes

Yes

No

No

If the answer is yes, go to question 1A to the
right. Otherwise, go to Question 2 below.

If yes, go to question 1B. If no, you
are done. Go to Section 7 of the
application.

Box 2. Is the business primarily involved in
for-hire fishing services (charter, party/
headboat)?

2A) Was the business active prior to
this year?

Yes

No

If the answer is yes, go to question 2A to the
right. Otherwise, go to Question 3 below.

Box 3. Is the business primarily involved in
buying and selling seafood (seafood
dealer/wholesaler)?
Yes

No

Yes

No

If yes, go to question 2B. If no, you
are done. Go to Section 7 of the
application.

3A) Was the business active prior to
this year?
Yes

No

If the answer is yes, go to question 3A to the
right. Otherwise, go to Question 4 below.

If yes, go to question 3B. If no, you
are done. Go to Section 7 of the
application.

Box 4. Is the business primarily involved in
processing seafood (seafood processor)?

4A) Was the business active prior to
this year?

Yes

Yes

No

If the answer is yes, go to question 1A to the
right. Otherwise, go to Question 5 on the next
page.

No

If yes, go to question 4B. If no, you
are done. Go to Section 7 of the
application.

Next page
5

1B) What was the most recent year the
business was active prior to this year?
_____________
Did the business have more than $11 million in
gross receipts in that year? Yes
No
You are done. Go to Section 7 of the
application.

2B) What was the most recent year the
business was active prior to this year?
_____________
Did the business have more than $8 million in
gross receipts in that year? Yes
No
You are done. Go to Section 7 of the
application.

3B) What was the most recent year the
business was active prior to this year?
_____________
Did the business have more than 100
employees? Yes
No
You are done. Go to Section 7 of the
application.

4B) What was the most recent year the
business was active prior to this year?
_____________
Did the business have more than 750
employees? Yes
No
You are done. Go to Section 7 of the
application.

SECTION 6 - SMALL BUSINESS OR ORGANIZATION CERTIFICATION
(Continued from previous page)

Box 5. Is the organization an Environmental,
Conservation and Wildlife, or Professional
Non-Profit Organization?

Yes

No

Box 5. Is the organization some other NonProfit Organization (e.g., business association)?

Yes

No

5A) Was the organization active
prior to this year?
Yes

organization was active prior to this year?
_____________

No

Did the organization have more than $15

If yes, go to question 5B.

Million in gross receipts?

If no, STOP! You are done.

STOP! You are done.

6A) Was the organization active
prior to this year?

6B) What was the most recent year the

Yes

If the answer is yes, go to question 6A to the
right. Otherwise, go to Question 7 below.

5B) What was the most recent year the

Yes

No

business was active prior to this year?

_____________

No

Did the organization have more than $7.5

If yes, go to question 6B.

Million in gross receipts? Yes

If no, STOP! You are done.

STOP! You are done.

No

7) The business or organization must be primarily involved in another industry not related to fishing or seafood.
Refer to SBA’s list of North American Industry Classification System (NAICS) codes
(see https://www.sba.gov/document/support--table-size-standards ) and enter the NAICS code for your primary activity here:

Based on the applicable SBA size standard, check the appropriate box to indicate if the business or organization is Large or Small and
report the year on which that conclusion was based.

Large

Small

Year:

STOP! You are done.

SECTION 7 - SIGNATURE FOR APPLICATION - REQUIRED
The undersigned certifies under penalty of perjury that the foregoing information is true and correct (28 U.S.C. section 1746; 18 U.S.C. section
1621; 18 U.S.C. section 1001).
Please note: The applicant who signs below must be the dealer identified in Section 1 unless the dealer is a partnership, corporation, or other
business entity, in which the applicant must be an individual named as an officer or shareholder of the business as listed in Section 5.
Applicant Signature

Date

Printed Name

Position In Company (if applicable)

Payment Reminder:
All applications must include payment of a non-refundable application fee in the form of a check or money order made payable to the U.S.
Treasury. The fee required is $50.00 for the first permit and $12.50 for each additional permit requested with this application.

6