Form 3-200-90 Federal Fish and Wildlife Permit Application Form - Spec

FWS Form 3-200-90 (Rev. 04/2020) OMB Control No. 1018-####

U.S. Department of the Interior Expires ##/##/####

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

Special Double-Crested Cormorant

(Migratory Bird Treaty Act; 50 CFR 21.28)

U.S. Fish and Wildlife Service

Division of Migratory Bird Management

TYPE OF REQUEST

New Application

Renewal

Amendment

If requesting a renewal or amendment, please provide the permit #: _____________________

BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to obtain the email/postal mail addresses where this form can be returned), and read the form Frequently Asked Questions and Instructions. Please retain the "NOTICES" page for your records.

NOTE: A Federal Special Double-Crested Cormorant permit is available only to a State or Tribal wildlife management agency responsible for migratory bird management on lands under their jurisdiction. Anyone conducting activities under authority of this permit must be listed as a subpermittee. Subpermittees must be at least 18 years old. Nonlethal methods to resolve conflicts must be attempted before lethal take occurs.

Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See instruction page(s) for information on how to make your application complete and help avoid unnecessary delays.

A. Complete if applying as an individual
1.a. Last name		1.b. First name	1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)	3.a. Telephone number	3.b. Alternate telephone number	3.d. E-mail address

B. Complete if applying on behalf of a State agency or Tribe
1.a. Name of agency or Tribe
4.a. Principal officer Last name		4.b. Principal officer First name			4.c. Principal officer Middle name/ initial	4.d. Suffix
5. Principal officer title				6. Primary contact name
7.a. Business telephone number	7.b. Alternate telephone number		7.c. Business fax number		7.d. Business e-mail address

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	2.c. State	2.d. Zip code/Postal code:	2.e. County/Province	2.f. Country

D. All applicants MUST complete

1. Processing fees – none required. Tribal and State agencies, and those acting on behalf of such agencies, are exempt from the processing fee (50 CFR 13.11(d)(3)(i).

2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?

Yes No If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue: ___________________

^3. 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.

__________________________________________________________________________________ __________________________

Signature of applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.) Date of signature (mm/dd/yyyy)

Please continue to next page

SECTION E

1. A brief description of your State's or Tribe's double-crested cormorant conflicts, including physical location(s). If you wish to provide site-specific information in decimal degrees (e.g. 36.87998/ -88.3435) where conflicts occur, visit https://earthexplorer.usgs.gov/.

2. A detailed statement explaining how the proposed cormorant management and take activities you propose will address human health and safety concerns, protect State- or Tribal-owned property and assets, protect threatened and endangered species (including species listed in your State or Tribal legislation), alleviate depredation at State- or Tribal-owned or operated aquaculture facilities, or prevent/reduce depredation of wild or publicly stocked fisheries stocked by State agencies or federally recognized Tribes.

3. The number of double-crested cormorants, including eggs and nests that you propose to take annually.

4. A statement indicating what information is available and will be collected to assess whether the management and take of double-crested cormorants is alleviating the damage or other conflict.

5. A statement indicating that the State or Tribe will ensure that all employees and subpermittees are fully informed and briefed regarding the regulatory requirements and conditions of this permit.

6) List of all subpermittees who may conduct activities under the Special Double-Crested Cormorant Permit, including their names, addresses, and telephone numbers.

7) The name and telephone number of the individual in your agency who will be in charge of the double-crested cormorant management activities authorized under your permit.

8. I acknowledge that I have read the form Instructions and Frequently Asked Questions, and have accessed the page with the Return Addresses to obtain the address where I should return this form. I have also filled out all fields and questions in this application. Check this box to acknowledge.

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 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 that affect protected species. The information the individual provides helps the 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

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a permit is requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. 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 above 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-#####.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information averages:

Paper-based submission: 16 hours (reporting)

Electronic submission: 14 hours (reporting)

These estimates include time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding these burden estimates or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this address.

FREEDOM OF INFORMATION ACT STATEMENT

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request you identify any information that should be considered privileged and confidential information to allow the Service to meet its responsibilities under the Freedom of Information Act (FOIA). Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page, and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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