Form 3-2439 Hunt Application/Permit - National Wildlife Refuge Syste

F WS Form 3-2439 (Rev. 06/2019) OMB Control. No. 1018-0140

U.S. Fish and Wildlife Service Expiration Date 07/31/2021

HUNT APPLICATION/PERMIT

National Wildlife Refuge System

[NAME OF REFUGE]

[Insert address, phone number, email,

Website, and/or other pertinent info]

PERMIT (Refuge Use Only) [Refuges can customize this section to meet their specific permit issuance procedures/types]

Permit Number/Type: ___________________ Valid for Season: ___________________________________________

Follow instructions in the refuge hunt publication; not all fields may be required. Read and comply with all refuge regulations, including application deadlines. [Refuge to insert submission instructions and deadline information here.]

Day Hunting Authorized [Refuge to customize with refuge-specific night hunting instructions]

Night Hunting Authorized [Refuge to customize with refuge-specific night hunting instructions]

Lottery Application (Lottery Deadline: [Refuge to insert lottery deadline information])

Hunt Permit Application License Type State Hunting License No.

Date of Application _________________ [Refuge to customize license type options]      

Method (Check all that apply) Species Permit Type (Check all that apply)

Rifle Shotgun Archery Deer Turkey Feral Hog Migratory Bird Waterfowl Raccoon

Falconry Muzzleloader Opossum Youth Turkey Youth Hunt Other (Describe)      

Primary Hunter Contact Information Check if Youth Hunter (Aged ## through ## years old)

Full Legal Name Age at Time of Hunt (Youth Hunter Only)

           

Mailing Address City State Zip Code

                       

Daytime Phone (Incl. Area Code) Cell Phone (Incl. Area Code) Email Address

                 

Party Members [Refuges may customize this section to allow addt’l names (only) of additional hunters, if applicable]

1.       2.       3.      

Parent/Guardian Contact Information (Required Only for Youth Hunters)

Full Legal Name of Parent/Guardian Relationship to Youth Description for “Other”

           

Hunter’s Mailing Address City State Zip Code

                       

Daytime Phone (Incl. Area Code) Cell Phone (Incl. Area Code) Email Address

                 

Hunt Dates

[Refuges may customize this section to provide details about their season dates]

Important Additional Information

[Refuges may customize this section with details about hunting locations/blind locations or special hunt opportunities]

I have read and understand the refuge hunt regulations and agree to abide by the regulations governing hunting on the refuge. [Refuges to insert applicable CFR citation for regulations]

______________________________ ______________________________ ______________________________

Hunter Signature Parent/Guardian Name (Printed) Parent/Guardian Signature

(Required for hunters less than ## years old)

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

FOR USFWS USE ONLY

(Refuge can customize this section)

Date Received: Payment Exempt/No Fee Payment Required Payment Amount:

Payment Type: Personal Check Cashier’s Check Money Order Other:

Notes:

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 waterfowl 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 10 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: JAO/1N, Falls Church, VA 22041-3803, or via email at [email protected]. Do not send your completed application to this address.

APPLICANT DOES NOT NEED TO PRINT OR RETURN THIS PAGE