Form 3-200-56 Incidental Take Permits Associated with a Habitat Conser

OMB Control No. 1018-0094

Expires _______

Department of the Interior U.S. Fish and Wildlife Service (FWS) Federal Fish and Wildlife Permit Application Form

Return to: U.S. Fish and Wildlife Service (USFWS) click here for return addresses

Type of Activity: Native Endangered and Threatened Species – Incidental Take Permits Associated with a Habitat Conservation Plan (HCP)

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 attached instruction pages 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. Occupation

4. Affiliation/ Doing business as (see instructions)

4.b. Website URL (if applicable)

5.a. Telephone number

5.b. Alternate telephone number

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

3.b. Website URL (if applicable)

4.a. Principal officer (P.O.) Last name

4.b. P.O. First name

4.c. P.O. Middle initial

4.d. P.O. email

5. P.O. title

6. Primary contact name

7.a. P.O. telephone number

7.b. Alternate phone no.

8.a. Primary contact telephone no.

8.b. Primary contact 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.

Check or money order payable to the U.S. FISH AND WILDLIFE SERVICE in the amount indicated on pages 2-3 (nonrefundable processing fee). 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.

Do you currently have or have you ever had any Federal Fish and Wildlife permits?  Yes If yes, list the number of the most current permit you have held or that you are applying to renew: ___________________________  No

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 Principal Officer (No photocopied or stamped signatures) Date of signature (mm/dd/yyyy)

** See page 15 for additional instructions on completing the above form. See page 16 for information on the Paperwork Reduction Act, Privacy Act, and Freedom of Information Act aspects of this application form.

Section E. ALL APPLICANTS COMPLETE SECTION E. Provide the information outlined in Section E. on the following pages. Be as complete and descriptive as possible. Please do not send pages that are over 8.5” x 11”, videotapes, or DVDs.

INCIDENTAL TAKE PERMITS ASSOCIATED WITH A

HABITAT CONSERVATION PLAN (HCP)

Have you obtained all required Federal, tribal, State, county, municipal or foreign government approval to conduct the activity you propose? Please be aware that there may be other requirements necessary to conduct this activity such as an import permit, collection permit, permission to work on Federal or tribal lands, Federal bird banding permit, Corps of Engineers permits, Environmental Protection Agency NPDES permits, tribal, State, county or municipal permits, etc.

 Yes. Provide a copy of the approval(s). List the Federal agency, tribe, State, county, municipality or foreign countries involved and type of document required. Include a copy of these documents with the application.

 I have applied. List the Federal agency, tribe, State, county, municipality or foreign countries involved and type of documents required. Provide the reasons why the permits have not been issued.

_________________________________________________________________________________________

 Not required. The proposed activity is not regulated.

Application Processing Fees

You may update your name, address, telephone number, fax number, or e-mail address in your current application package on file at any time. These changes are considered an administrative change, and no application processing fee is required. If you wish to make an administrative change, please fill out page 1 and indicate the information that you are updating. Then check the box below, provide your permit number, and send the completed pages 1-2 to the appropriate Regional Office (see attached list).

 Administrative change for permit number: ________________________.

If you wish to make changes other than an administrative change, then an application processing fee is required as described below.

The application processing fee for a new Incidental Take permit, or to renew or substantively amend an existing valid permit (changes that exceed the original review analyses) is $100. If permit amendment (with less substantive changes) is required at a time other than renewal, the processing fee is $50. For additional information on the application processing fee and the requirements to qualify for a fee exemption, please see the instructions for section D. on page 15.

If the information in your current application package on file has changed in a manner that triggers a substantive amendment or a change not otherwise specified in the permit, then you must apply for a substantive amendment to your valid permit. For example, such major changes may include changes in location, activity, amount or type of take, or species to be covered by the permit. Please contact our Ecological Services Field Office located closest to your proposed activity for technical assistance in making this determination. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish and Wildlife Service’s (Service) office directory web page at http://www.fws.gov/offices

Check the appropriate box below and enclose check or money order payable to the U.S. Fish and Wildlife Service in the amount of:

 $100 [or  fee exempt (attach justification if required)] for a new permit. Use Option I. below to provide the required information.

OR

 $100 [or  fee exempt (attach justification if required)] to renew or substantively amend my existing valid permit (with major changes) using my current application package on file. Use Options I. and II. below to provide the required information. Please indicate the information that you are changing.

OR

 $100 [or  fee exempt (attach justification if required)] to renew my existing valid permit (without changes) using my current application package on file. Use Option III. below to provide the requested information.

OR

 $50 [or  fee exempt (attach justification if required)] to amend my existing valid permit (with minor changes) at a time other than permit renewal. Use Options I. and II. below to provide the required information. Please indicate the information that you are changing.

Please check the type of amendment you are requesting –

 add species (specify) ________________________________________________________________________________

 add new activity with previously permitted species (specify) _________________________________________________

 add a geographic area  change in personnel

 other (specify) ____________________________________________________________________________________

If this application includes transfer or succession of a valid Incidental Take permit, please check the box below:

• Transfer or succession of a valid Incidental Take permit associated with a HCP using the current application package on file. No application fee is required, but you must submit a new application signed by the transferee or successor along with signed assumption agreement by the permitee and transferee or successor.

Application Processing

To expedite a final decision on your application, you are urged to coordinate with us as soon as possible for guidance in assembling a complete application package. If you are renewing or amending a valid permit, your complete application package must be received at least 30 days prior to the expiration of the valid permit. The following estimates of application processing time begin with our acceptance of a complete permit application package and do not include any time required for requesting clarification or additional information about your application.

The time required to process an application for an Incidental Take permit will vary depending on the size, complexity, and impacts of the HCP involved. Procedurally, the most variable factor in application processing is the level of analysis required for the proposed HCP under the National Environmental Policy Act (e.g., whether an application requires preparation of an Environmental Impact Statement, Environmental Assessment, or whether a categorical exclusion applies), although other factors such as public controversy can also affect application processing times.

The information provided in your permit application will be used to evaluate your application for compliance with the Endangered Species Act, its implementing regulations (which may require a 30- or 90-day public comment period), and with U.S. Fish and Wildlife Service policy. Receipt and possession of a permit under the Endangered Species Act should be regarded as a privilege, as we must balance permit issuance with our duties to protect and recover listed species.

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for renewal, re-issuance or amendment.

If your activities may affect species under the authority of the National Marine Fisheries Service (NMFS/NOAA Fisheries), then you may need to obtain a separate permit from that agency. In addition we share jurisdiction with NMFS/NOAA Fisheries for sea turtles (e.g., we evaluate applications for permits to conduct activities impacting sea turtles on land, and NMFS/NOAA Fisheries evaluates applications for permits to conduct activities impacting sea turtles in the marine environment). To apply for a permit to conduct activities with sea turtles in the marine environment or other species under NMFS/NOAA Fisheries jurisdiction, please contact them

via their permit web page at http://www.nmfs.noaa.gov/pr/permits/.

We cannot issue an Incidental Take permit under Section 10(a)(2)(A) of the Endangered Species Act unless the applicant submits a conservation plan that specifies: (i) the impacts that are likely to result from the incidental take associated with the applicant’s activity; (ii) what steps the applicant will take to minimize and mitigate such impacts, and the funding that will be available to implement such steps; (iii) what alternative actions to such taking the applicant considered and the reasons why such alternatives are not being utilized; and (iv) such other measures that the Secretary may require as being necessary or appropriate for purposes of the plan.

Permits for Biological Surveys: Our general permit regulations at 50 CFR 13.12(a)(9) allow us to collect such other information as we determine that is relevant to the processing of a permit application. Before you submit an application for an Incidental Take permit, we may require that you conduct biological surveys to determine which species and/or habitat would be impacted by the activities sought to be covered under the permit. Biological surveys provide information necessary to develop an adequate HCP, and to assess the biological impacts of the proposed activities. In addition, the information provided in a biological survey can reduce the applicant’s risk of take under Section 9 of the Endangered Species Act by ensuring that affected species and/or habitat are identified and appropriately covered under the permit.

Option A: You are required to obtain a Scientific Purposes, Enhancement of Propagation or Survival permit (commonly called a Recovery permit) from us before engaging in any biological survey activities that would take listed species. Contact our Ecological Services Field Office closest to the location of your activity to obtain technical assistance in determining the need for both a biological survey and a Recovery permit for your survey activity. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish and Wildlife Service’s office directory web page at http://www.fws.gov/offices.

If a biological survey is required, you will need to send us your complete Recovery permit application package and have it accepted at least 3 months prior to commencement of survey activities to facilitate processing of your Recovery permit application. The Recovery permit application is designated as U.S. Fish and Wildlife Service form # 3-200-55 and can be found on our Endangered Species permit web page at http://www.fws.gov/forms/3-200-55.pdf.

Option B: You may hire biological consultants who already hold Recovery Permits to conduct biological surveys on your behalf. We maintain a list of Recovery permittees who have authorized the release of their contact information to third parties for conducting biological surveys on a contract basis. This list is provided to the public at the discretion of each U.S. Fish and Wildlife Service Regional Office as time and workload allow. Please be aware that this list does not represent an endorsement by us of any particular permittee.

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If you are not applying as an individual but as a business, corporation, tribe, institution, or non-Federal public agency (block B. on page 1 of the application), the person to whom the permit will be issued (e.g., the landowner, president, director, executive director, or executive officer) is legally responsible for implementing the permit. Although other people under the direct control of the permittee (e.g., employees, contractors, consultants) receive third party take authorization in their capacity as designees of the permittee, the individual named as the permittee ultimately is legally responsible for the permit and any activities carried out under the permit except as otherwise limited in the case of permits issued to State or local government entities under 50 CFR 13.25(e).

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If you wish to coordinate the processing of this permit application through an authorized agent, and to have that agent represent you as the primary contact with us, check the box below. Sign (in blue ink) and date the authorization statement, and provide contact information for your authorized agent.

 I hereby authorize the following person to act as an authorized agent on my behalf in the processing of this permit application and to furnish, upon request, supplemental information in support of this permit application.

__________________________________ __________________

signature (in blue ink) date

_________________________________

please print name legibly

Your Authorized Agent’s Contact Information (please print legibly)

Name: _________________________________________________________________________

Address: _________________________________________________________________________

City: ___________________________________ State: ___________ Zip Code:____________

Telephone: ____________________________ Cell Phone: _______________________________

E-Mail: _________________________________________________________________________

INCIDENTAL TAKE PERMIT APPLICATION INSTRUCTIONS

You have four options for providing the required information for an Incidental Take permit application.

Incidental Take Permit Application: Option I. New Incidental Take Permit & Supplementary Information for Renewal or Amendment of an Existing Valid Permit (With Changes).

General permit regulations for the U.S. Fish and Wildlife Service can be found at 50 CFR 13. Regulations for an Incidental Take permit under the Endangered Species Act can be found at 50 CFR 17.22(b)(1) for endangered wildlife species and 50 CFR 17.32(b)(1) for threatened wildlife species.

Each landowner who wishes to be covered under a new or amended Incidental Take permit associated with an HCP must sign (in blue ink) and date the Incidental Take Permit Application Certification Notice at the end of this application, unless the landowner will be covered under this U.S. Fish and Wildlife Service Incidental Take permit via another vehicle, such as a certificate of inclusion (50 CFR 13.25(d)). Any change in the language of the Certification Notice must be reviewed by the Department of the Interior, Office of the Solicitor and approved by the U.S. Fish and Wildlife Service. The same person who signs in box D. on page 1 of the application must sign the certification.

If the information in items A. - D. below is already provided in your final HCP (or Implementing Agreement, if applicable), then you do not have to provide it here. Instead, check the box below and use the spaces provided in items A. - D. to indicate the page numbers in your HCP or Implementing Agreement that provide the requested information.

 I am not providing the following information for items A. - D. as part of my Incidental Take permit application, because it is already provided in my final HCP or Implementing Agreement (copy attached or already submitted).

 I am not providing the following information for items A. - D. as part of my Incidental Take permit application, because I am participating in a General Conservation Plan or Programmatic HCP that is already approved and on file with the appropriate U.S. Fish and Wildlife Service Regional Office.

If the requested information in items A. - D. is not provided in your final HCP or final Implementing Agreement, or you are using Option II. to renew or amend your existing valid Incidental Take permit, then attach separate pages for the missing information. In order to assist us in processing your request, please provide the item number (A. 1.a., etc.) of the required information before each of your responses. Thank you.

Please ensure that your final HCP and Implementing Agreement (if applicable) are attached if it has not been previously submitted.

If you have previously submitted a final draft HCP or Implementing Agreement, please indicate the document’s date.

Date of final draft HCP ____________

Date of final draft Implementing Agreement ______________

Applications for an Incidental Take permit associated with an HCP must provide the following specific information (relevant to the activity) under items A.- D. below in addition to the general information on pages 1-5 of this application.

A. Identify species and activity:

1. For a new Incidental Take permit:

a. Provide the common and scientific names of the species requested for coverage in the permit and their status (endangered (E), threatened (T), proposed endangered (PE), proposed threatened (PT), candidate for listing (C), or species likely to become a candidate (LC)).

b. Provide the number, age, and sex of such species to the extent known.

c. Quantify the anticipated effects to their habitat.

d. Describe each activity associated with your project that would result in the incidental take of each species.

2. For an amended Incidental Take permit:

a. Identify the activities and/or species to be added to your valid permit (provide both the scientific, to the most specific taxonomic level, and common names), as well as the species status (see 1.a., above).

b. Provide the number, age and sex of such species to the extent known.

c. If any activities requested in this application differ from those in your valid permit, then for each species state the current activity, the requested new activity, and how the new activity will impact each species.

d. Describe each activity associated with your project that would result in the incidental take of each species.

e. Quantify any anticipated effects to the habitat of each added species.

f. Identify activities and/or species to be deleted from your valid permit and the reason(s) for the deletion.

Page(s) & source document: ____________________________________________________________________

B. Identify location of the proposed activity:

1. Provide the name of the State, county, tribal land, and the specific location of the proposed activity site(s). Include a formal legal description, section/township/range information, county tax parcel number, local address, or any other identifying property designation that will precisely place the location of the proposed activity site(s). Attach a location map and plat of the project site clearly depicting the project boundaries and the footprint and location of all portions of the property that would be affected by your proposed activities.

2. Provide the total number of acres covered by the HCP ____________

Is this the total acreage of the parcel? (check one) yes no

3. Provide the approximate number of acres to be impacted _____________

4. Provide the approximate number of acres to be protected _____________

5. Provide a complete description, including timeframes, for implementation of proposed voluntary management activities to enhance, restore, or maintain habitat benefiting federally listed, proposed or candidate species, or other species likely to become candidates. Include schedules for implementing these activities.

Page(s) & source document:____________________________________________________________________

C. Describe the proposed activities in the conservation plan:

You must submit a Habitat Conservation Plan. We strongly encourage you to ensure that your HCP is consistent with the Habitat Conservation Planning Handbook, subsequent Handbook addendums, and current policies in order to minimize delays in evaluating your application. The Handbook and other HCP information is available on the U.S. Fish and Wildlife Service’s Endangered Species web page at http://www.fws.gov/endangered/what-we-do/hcp-overview.html.

Provide a complete description of activity(ies) or reference the applicable HCP page numbers identifying the subject information.

The HCP must specify:

1. The impact that will likely result from the incidental taking. A discussion of the impact that will likely result from the incidental take must include quantification of any anticipated effects to the habitat of the species sought to be covered by the permit.

2. The steps that will be taken to minimize and mitigate such impacts, the funding that will be available to implement such steps, and the procedures to deal with unforeseen circumstances.

3. The steps that will be taken to monitor and report on such impacts, including a copy of the monitoring plan. We are authorized to require reports of activities conducted under a permit per the U.S. Fish & Wildlife Service’s general permit regulations at 50 CFR 13.45.

4. Alternative actions to such incidental taking that have been considered and the reasons why these alternatives are not proposed for use.

5. The biological goals(s) and objectives for the HCP.

6. The duration requested for the proposed permit.

Page(s) & source document: ___________________________________________________________________

D. Implementing Agreement (Voluntary)

An Implementing Agreement

is is not (USFWS Regional Office to circle one)

a part of the permit application for a Habitat Conservation Plan.

If you wish to develop an Implementing Agreement, it must be signed at finalization of the HCP. Are you willing to commit to an Implementing Agreement at finalization of the HCP?

 Yes, I am willing to commit to an Implementing Agreement. Please submit any unsigned, draft Implementing Agreement that you have prepared with our Field Office.

 No, I am not willing to commit to an Implementing Agreement.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option II. Renewal or Amendment of an Existing Valid Incidental Take Permit (With Changes)

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for renewal or amendment.

Sign the following statement if you are proposing to renew or amend an existing valid Incidental Take permit, including making substantive changes. Such changes may include changes in location, activity, amount or type of take, or species to be covered by the permit.

The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification language is required under 50 CFR 13.22(a).

I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife Service Incidental Take permit # ________________ are still current and correct, except for the changes listed in Option I. above, and hereby request (please check either  renewal or  amendment) of that permit.

_________________________ __________________

signature (in blue ink) date

__________________________

please print name legibly

Provide a brief description of the changes to your valid permit (answer the appropriate questions for these changes requested under Incidental Take Permit Application Option I. above). Please submit completed pages 1 - 9 of this application form (along with the changed information relative to Option I. above) to our Regional Office (see attached list) covering the location of your proposed activity.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option III. Renewal of an Existing Valid Incidental Take Permit (Without Changes) Using My Current Application Package On File.

Up-to-date annual reports and any other required reports under your valid permit(s) must be on file before a permit will be considered for renewal.

Sign the following statement if you are applying to renew or re-issue an existing valid Incidental Take permit without changes. If you are proposing changes to your Incidental Take permit, you must use Options I. and II. above.

The individual signing box D. on page 1 of the application must also sign (in blue ink) the following statement. This certification language is required under 50 CFR 13.22(a).

I certify that the statements and information submitted in support of my original application for a U.S. Fish and Wildlife Service Incidental Take permit # ______________ are still current and correct and hereby request a renewal of that permit without changes.

_________________________ __________________

signature (in blue ink) date

_________________________

please print name legibly

* Please note: If you have signed the above statement, then your renewal request is complete. Please submit this page and completed pages 1- 5 of this application to our Regional Office (see attached list) covering the location of your proposed activity. Requests for renewals must be complete and accepted by the Service no later than 30 days prior to permit expiration to ensure that your current permit remains in effect while we process your request.

_________________________________________________________________________________________________________

Incidental Take Permit Application: Option IV. Permit Transfer or Succession of a Permit

Complete the following if you are applying for transfer of an existing valid Incidental Take permit to you or obtaining rights of succession of an existing valid Incidental Take permit. In addition, you and the current permit holder may also need to sign an Assumption Agreement. Please contact our Ecological Services Field Office nearest your activity to determine whether you and the current permit holder need to execute an Assumption Agreement. The contact information for our Ecological Services Field Offices can be found on the U.S. Fish and Wildlife Service’s office directory web page http://www.fws.gov/offices.

Please indicate the name of the HCP to be transferred or succeeded, and indicate the document’s date.

Name of HCP ____________________________________________________

Date of HCP _________________________

An Assumption Agreement

is is not (USFWS Ecological Services Field Office to circle one)

required as part of the transfer or succession permit application for the HCP.

_________________________________________________________________________________________________________

Incidental Take Permit Application

Certification Notice

The same person who signs in box D. on page 1 of the application must sign (in blue ink) the following certification.

By submitting this application and receiving an Incidental Take permit pursuant to Section 10(a)(1)(B) of the Endangered Species Act, I

___________________________________________________________(print name(s)) attest that I/we own the lands indicated in this application, or have sufficient authority or rights over these lands to implement the measures of the Habitat Conservation Plan (and Implementing Agreement, if applicable) covered by the Incidental Take permit. Further, upon receipt of the Incidental Take permit, I/we agree to conduct the activities as specified in the Habitat Conservation Plan (and Implementing Agreement, if applicable) according to the terms and conditions of the Incidental Take permit and its supporting documents.

__________________________________ ______________

signature (in blue ink) date

__________________________________

please print name legibly

__________________________________ ______________

signature (in blue ink) date

__________________________________

please print name legibly

USFWS Regional Contacts for Native Endangered and Threatened Species Permits

Pacific Region (Region 1): HI, ID, OR, WA, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and the Pacific Trust Territories

U.S. Fish and Wildlife Service, Endangered Species Permit Office

911 NE 11th Avenue

Portland, Oregon 97232-4181

Web: http://www.fws.gov/pacific/ecoservices/endangered/index.html

Phone: (503) 231-6131 email: [email protected]

Fax: (503) 231-6243

Southwest Region (Region 2): AZ, NM, OK, and TX

U.S. Fish and Wildlife Service, Endangered Species Permit Office

500 Gold Avenue S.W. (street address)

P.O. Box 1306 (mailing address)

Albuquerque, New Mexico 87103-1306

Web: http://www.fws.gov/southwest/es/EndangeredSpecies_Main.html

Phone: (505) 248-6649 email: [email protected]

Fax: (505) 248-6788

Midwest Region (Region 3): IA, IL, IN, MI, MN, MO, OH, and WI

U.S. Fish and Wildlife Service, Endangered Species Permit Office

5600 American Blvd. West, Suite 990

Bloomington, MN 55437-1458

Web: http://www.fws.gov/midwest/Endangered/

Phone: (612) 713-5343 email: [email protected]

Fax: (612) 713-5292

Southeast Region (Region 4): AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN, and U.S. Virgin Islands

U.S. Fish and Wildlife Service,

Endangered Species Permit Office

Ecological Services

1875 Century Blvd.

Atlanta, Georgia 30345

Web: http://www.fws.gov/southeast/es/

Phone: (404) 679-7097 (10(a)(1)(A) permit coordinator) or (404) 679-7140 (R4 Endangered Species main office)

email: [email protected]

Fax: (404) 679-7081

Northeast Region (Region 5): CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VA, VT, and WV

U.S. Fish and Wildlife Service, Endangered Species Permit Office

300 Westgate Center Drive

Hadley, MA 01035-9589

Web: http://www.fws.gov/northeast/EcologicalServices/endangeredspecies.html

Phone: (413) 253-8628 email: [email protected]

Fax: (413) 253-8482

Mountain-Prairie Region (Region 6): CO, KS, MT, NE, ND, SD, UT, and WY

U.S. Fish and Wildlife Service, Endangered Species Permit Office

Denver Federal Center

P.O. Box 25486

Denver, Colorado 80225-0489

Web: http://www.fws.gov/mountain-prairie/endspp/

Phone: (303) 236-4256 email: [email protected]

Fax: (303) 236-0027

Alaska Region (Region 7): AK

U.S. Fish and Wildlife Service, Endangered Species Permit Office

1011 E. Tudor Road

Anchorage, Alaska 99503-6199

Web: http://alaska.fws.gov/fisheries/endangered/index.htm

Phone: (907) 786-3323 email: [email protected]

Fax: (907) 786-3350

Pacific Southwest Region (Region 8): CA, NV and Klamath Basin

U.S. Fish and Wildlife Service,

Endangered Species Permit Office

2177 Salk Avenue, Suite 250

Carlsbad, California 92008

Web: http://www.fws.gov/cno/es/

Phone: (760) 431-9440 email: [email protected]

APPLICATION FORM INSTRUCTIONS

The following instructions pertain to U.S. Fish and Wildlife Service (USFWS) permit applications. The General Permit Procedures in 50 CFR 13 address the permitting process. For simplicity, all licenses, permits, registrations, and certificates are referred to as a permit.

GENERAL INSTRUCTIONS:

• Complete all relevant questions in Sections A or B, C, D, and E.

• An incomplete application may cause delays in processing or may be returned to the applicant. Be sure you are filling in the appropriate application form for the proposed activity.

• Print clearly or type in the information. Illegible applications may cause delays.

• Sign the application in blue ink. Faxes or copies of the original signature will not be accepted.

• Mail the original application to the address at the top of page one of the application or, if applicable, on the attached address list.

• Keep a copy of your completed application.

• Please plan ahead. Allow at least 90 days for your application to be processed; however, some applications may take longer than 90 days to process (50 CFR 13.11).

• Applications are processed in the order in which they are received.

SECTION A OR SECTION B:

Section A. Complete if applying as an individual [do not complete this section if applying for Import/Export License (3-200-3)]:

• Enter the complete name of the responsible individual who will be the permittee if a permit is issued. Enter personal information that identifies the applicant. Fax and e-mail, while helpful in processing, are not required.

• If you are applying on behalf of a client, the personal information must pertain to the client, and a document evidencing power of attorney must be included with the application.

• Affiliation/Doing business as (dba): business, agency, organizational, tribe, or institutional affiliation directly related to the activity requested in the application (e.g., a taxidermist is an individual whose business can directly relate to the requested activity). The Division of Management Authority (DMA) and the Office of Law Enforcement (OLE) do not accept doing business as affiliations for individuals (complete Section B).

Section B. Complete if applying as a business, corporation, public agency, tribe, or institution:

• Enter the complete name of the business, agency, tribe, or institution that will be the permittee if a permit is issued. Give a brief description of the type of business the applicant is engaged in. Provide contact phone number(s) of the business. If you are applying on behalf of a client, a document evidencing power of attorney must be included with the application.

• Principal Officer is the person in charge of the listed business, corporation, public agency, tribe, or institution. The principal officer is the person responsible for the application and any permitted activities. Often the principal officer is a Director or President. Primary Contact is the person at the business, corporation, public agency, tribe, or institution who will be available to answer questions about the application or permitted activities. Often this is the preparer of the application.

ALL APPLICANTS COMPLETE SECTION C:

• For all applications submitted to the DMA and OLE, a physical U.S. address is required. Province and Country blocks are provided for those USFWS programs that use foreign addresses and are not required by DMA.

• Mailing address is the address to which communications from USFWS should be mailed if different from the applicant’s physical address.

ALL APPLICANTS COMPLETE SECTION D:

Section D.1 Application processing fee:

• An application processing fee is required at the time of application, unless exempted under 50 CFR13. The application processing fee is assessed to partially cover the cost of processing a request. The fee does not guarantee the issuance of a permit, nor will fees be refunded for applications for which processing has begun.

• Documentation of fee exempt status is not required for applications submitted Federal, tribal, State, or local government agencies, but must be supplied by those applicants acting on behalf of such agencies. Such applications must include a letter on agency letterhead and signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be carrying out the permitted activity for the agency.

Section D.2 Federal Fish and Wildlife permits:

• List the number(s) of your most recently issued USFWS permit. If applying for re-issuance of a Conference on International Trade in Endangered Species (CITES) permit, the original permit must be returned with this application.

Section D.3 CERTIFICATION:

• The individual identified in Section A, the principal officer named in Section B, or person with a valid power of attorney (documentation must be included in the application) must sign and date the application in blue ink. This signature legally binds the applicant to the statement of certification. You are certifying that you have read and understand the regulations that apply to the permit. You are also certifying that all information included in the application is true to the best of your knowledge. Be sure to read the statement and re-read the application and your answers before signing.

Please continue to next page

APPLICATION FOR A FEDERAL FISH AND WILDLIFE PERMIT

Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices

In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:

1. The gathering of information on fish and wildlife is authorized by:

(Authorizing statutes can be found at: http://www.ecfr.gov/cgi-bin/text-idx?tpl=%2Findex.tpl and http://www.fws.gov/permits/ltr/ltr.html.)

a. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;

b. Endangered Species Act of 1973 (16 U.S.C. 1531-1544), 50CFR 17;

c. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;

d. Marine Mammal Protection Act of 1972 (16 U.S.C. 1361, et. seq.), 50 CFR 18;

e. Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15;

f. Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16;

g. Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), http://www.cites.org/, 50 CFR 23;

h. General Provisions, 50 CFR 10;

i. General Permit Procedures, 50 CFR 13; and

j. Wildlife Provisions (Import/export/transport), 50 CFR 14.

2. 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 (USFWS) to deny the request. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number.

3. Certain applications for permits authorized under the Endangered Species Act of 1973 (16 U.S.C. 1539) and the Marine Mammal Protection Act of 1972 (16 U.S.C. 1374) will be published in the Federal Register as required by the two laws.

4. Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)

a. Routine disclosure to subject matter experts, and Federal, tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a USFWS function related to this system of records.

b. Routine disclosure to the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the decision on a permit application.

c. Routine disclosure to Federal, tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with all applicable permitting requirements.

d. Routine disclosure to Captive‑bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive breeding of these species.

e. Routine disclosure to Federal, tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.

f. Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or administrative body, under certain circumstances.

g. Routine disclosure to the appropriate Federal, tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or regulated use.

h. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.

i. Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.

j. Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by the USFWS.

5. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application.

6. The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The relevant burden for an Incidental Take permit application is 3 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, Falls Church, Virginia 22041 U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.

Freedom of Information Act – Notice

For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered privileged and confidential business 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 2.23 and 43 CFR 2.24]