Form 3-2359 Big Game Harvest Report

OMB Control. No. 1018-0140
Expiration Date 06/30/2021

FWS Form 3-2359 (Rev. 02/2018)
U.S. Fish and Wildlife Service

BIG GAME HARVEST REPORT
National Wildlife Refuge System

1. Name of Refuge: _____________________________ 2. Date of Application: _____________________
3. Full Legal Name: _________________________________________________________________________
Mailing Address: ________________________________________________________________________
City: _____________________________ State: ______________________ Zip Code: _________________
Area Code/Phone No: ____________________________________________________________________
Email Address: __________________________________________________________________________
4. Date of Hunt: ___________________________________________________________________________
Time: From ____________

✔

am

pm To ________________

am

✔

pm

Total Hours Hunted: ____________________
Number in Party (Please check one)

1

Species
Note: Not all species are hunted on this refuge.
Check refuge regulations for details.
Deer
Feral Hog
Turkey
Other (specify):

2

3

Number Harvested

4

✔

5

Other: ______________

Male / Female
Male
Female
Male
Female
Male
Female
Male
Female

Size*

Comments:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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OMB Control. No. 1018-0140
Expiration Date 06/30/2021

FWS Form 3-2359 (Rev. 02/2018)
U.S. Fish and Wildlife Service

NOTICES
All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations
made in the application may be grounds for revocation of the permit and may be punishable by fine or imprisonment (18 U.S.C. 1001).
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as
amended and the Refuge Recreation Act (16 U.S.C. 460k – 460k-4).
Purpose: The collection of contact information is to verify that the individual has an eligible permit to hunt on one of the National
Wildlife Refuges that is designated for big game hunting.
Routine Uses: The individual’s contact information may be used to verify permit status, provide permittees with permit-related
information, and monitor waterfowl hunt activities conducted under a permit. More information about routine uses can be found in the
System of Records Notice, Permits System, FWS-21.
Disclosure: Providing the information is required as a condition of maintaining a Federal permit under the National Wildlife Refuge
System Administration Act. Failure to disclose the requested information may be sufficient cause for revocation of the permit. If the
information indicates a violation of a statute, regulation, rule, order or license, whether civil, criminal, or regulatory in nature, the
information may be transferred to the appropriate Federal, State, local or foreign agency charged with investigating or prosecuting such
violations.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the refuge managers the
information needed to decide whether or not to allow the requested use, and to respond to requests made under the Freedom of
Information Act and the Privacy Act of 1974. The information that you provide is voluntary; however, submission of the requested
information is required to evaluate the qualifications, determine eligibility, and document permit applicants. Failure to provide all
required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. 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. OMB has
approved this collection of information and assigned OMB Control No. 1018-0140.
ESTIMATED BURDEN STATEMENT
Public reporting for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg
Pike, MS: BPHC, Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed application to
this address.

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