Form 3-200-54 Enhancement of Survival Permits Associated with Safe Har

FWS Form 3-200-54 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1018-0094
Expires ##/##/20##

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM
Native Endangered and Threatened Species Enhancement of Survival Permits Associated with Safe Harbor Agreements
And Candidate Conservation Agreements with Assurances
Return to: U.S. Fish and Wildlife Service (USFWS)
click here for return addresses

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

2. Date of birth (mm/dd/yyyy)

3. Occupation

4.a. Affiliation/Doing business as (see instructions)

5.a. Telephone number

5.b. Alternate telephone number

6. E-mail address

1.d. Suffix

4.b. Website URL (if applicable)

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.d. P.O. e-mail address

5. P.O. title
7.a. P.O. telephone number

4.c. P.O. middle initial
6. Primary contact name

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 page 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))
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 or amend: ____________________
☐ No
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.

2.

3.

_____________________________________________________________________________________
Signature (in blue ink) of applicant/person responsible for permit (No photocopied or stamped signatures)

____________________________
Date (mm/dd/yyyy)

*See page 13 for additional instructions on completing the above form. See page 15 for information on the Paperwork Reduction Act, Privacy Act,
and Freedom of Information Act aspects of this application form.
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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.

ENHANCEMENT OF SURVIVAL PERMITS ASSOCIATED WITH SAFE HARBOR AGREEMENTS &
CANDIDATE CONSERVATION AGREEMENTS WITH ASSURANCES
What type of agreement are you requesting?
☐ Safe Harbor Agreement
OR
☐ Candidate Conservation Agreement with Assurances
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 Enhancement of Survival permit, or to renew/substantively amend an existing valid permit (with major
changes) is $50. If permit amendment (with minor changes) is required at a time other than renewal, the processing fee is $25. 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 14.
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 or the Safe Harbor Agreement/Candidate Conservation Agreement with Assurances, 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 (USFWS) 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:
☐ $50 [or  fee exempt (attach justification if required)] for a new permit. Use Option I. below to provide the required
information.
OR

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☐ $50 [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 Option II. below to provide the required information. Please
indicate the information that you are changing.
OR
☐ $50 [or ☐ fee exempt (attach justification if required)] to renew/re-issue my existing valid permit (without changes) using my
current application package on file. Use Option III. below to provide the requested information.
OR
☐ $25 [or ☐ fee exempt (attach justification if required)] to amend my existing valid permit (with minor changes) at a time
other than permit renewal. Use Option II. below to provide the required information. Please indicate the information that
you are changing.
OR
☐ $0 to transfer my existing valid permit. Use Option IV. Below to provide the required information.
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 Enhancement of Survival permit, please check the box below:
☐ Transfer or succession of a valid Enhancement of Survival permit associated with a Safe Harbor Agreement or Candidate Conservation
Agreement with Assurances using the current application package on file. No application fee is required. Note all transfers or successions
must include an application form signed by the “new” owner(s) and, in some cases, an assumption agreement (see instructions for
Option IV below).
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, and to send us your complete permit application package at least three months prior to the start of your proposed
activities. 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. These time periods begin with our acceptance of a complete permit application package, and does not include
any time required for requesting clarification or additional information about your application, or the length of time between our request and
your response.
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 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
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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/.
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 Enhancement of Survival 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 Safe Harbor Agreement or Candidate Conservation Agreement with Assurances, 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.
Permits for Biological Surveys
Option 1: 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 2: You may hire consultants who already possess Recovery Permits to conduct biological surveys. We maintain a list of Recovery
permittees (such as biological consultants) 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.
***********************************************************************************************************************
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).
************************************************************************************************************************
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)
______________________________________________
please print name legibly

________________________
date

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U.S. Department of the Interior

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Your Authorized Agent’s Contact Information (please print legibly)
Name: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
City: _______________________________________

State: ___________

Zip Code: ______________

Telephone: _________________________________

Cell Phone: ____________________________________

E-mail: _____________________________________

Fax: __________________________________________

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U.S. Department of the Interior

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ENHANCEMENT OF SURVIVAL PERMIT APPLICATION INSTRUCTIONS
You have 4 options for providing the required information for an Enhancement of Survival permit application.
Enhancement of Survival Permit Application: Option I. New Enhancement of Survival Permit
General permit regulations for the U.S. Fish and Wildlife Service can be found at 50 CFR 13. Regulations for an Enhancement of Survival permit
associated with a Safe Harbor Agreement under the Endangered Species Act can be found at 50 CFR 17.22(c)(1) for endangered wildlife species
and 50 CFR 17.32(c)(1) for threatened wildlife species. Regulations for an Enhancement of Survival permit associated with a Candidate
Conservation Agreement with Assurances under the Endangered Species Act can be found at 50 CFR 17.22(d)(1) for endangered wildlife species
and 50 CFR 17.32(d)(1) for threatened wildlife species.
Each landowner who wishes to be covered under a new or amended Enhancement of Survival permit associated with a Safe Harbor Agreement
or Candidate Conservation Agreement with Assurances must also sign (in blue ink) and date the Enhancement of Survival Permit Application
Certification Notice at the end of this application, unless the landowner will be covered under this U.S. Fish and Wildlife Service Enhancement
of Survival 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. - B. below is already provided in your final Safe Harbor Agreement or final Candidate Conservation Agreement with
Assurances, then you do not have to provide it here. Instead, check the box below and use the spaces provided in items A. - B. to indicate the
page numbers in your Agreement that provide the requested information.
☐ I am not providing the following information for items A. - B. as part of my Enhancement of Survival permit application,
because it is already provided in my final Safe Harbor Agreement or final Candidate Conservation Agreement with
Assurances (copy attached or already submitted).
If the requested information in items A. - B. is not provided in your final Safe Harbor Agreement or final Candidate Conservation Agreement with
Assurances, 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 Safe Harbor Agreement or Candidate Conservation Agreement with Assurances is attached if it has not been
previously submitted.
If you have previously submitted a final draft Safe Harbor Agreement or Candidate Conservation Agreement with Assurances, please indicate the
document’s date.
Date of final draft Safe Harbor Agreement ___________________________
Date of final draft Candidate Conservation Agreement with Assurances ___________________________
Applications for an Enhancement of Survival permit associated with a Safe Harbor Agreement or Candidate Conservation Agreement with
Assurances must provide the following specific information (relevant to the activity) under items A.- B. below in addition to the general information
on pages 1- 5 of this application.

A.

Identify species and activity:

1.

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)).

2.

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

3.

Quantify the anticipated effects to their habitat.

4.

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

5.

If you are applying for an Enhancement of Survival permit under a Safe Harbor Agreement, please provide a brief description of
the baseline population and habitat conditions for each listed species proposed for coverage under the Safe Harbor Agreement.
(Note: Baseline conditions must be summarized in a manner appropriate for each covered species, generally in terms of numbers
of individuals present or amount of suitable habitat.)

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B.

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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).

2.

Provide the total number of acres covered by the Agreement ________________
Is this the total acreage of the parcel? (check one)

☐ Yes

☐ No

3.

Provide the approximate number of acres to beimpacted ________________

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.

Page(s) & source document: _________________________________________________________________________________

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Enhancement of Survival Permit Application: Option II. Renewal or Amendment of an Existing Valid Enhancement of Survival 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 Enhancement of Survival permit with changes, including
making major changes. Such major 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
Enhancement of Survival permit #___________________________are still current and correct, except for the changes listed below, and
hereby request (please check either ☐ renewal or ☐ amendment) of that permit.
______________________________________________
Signature (in blue ink)
______________________________________________
Please print name legibly

___________________________
Date

Provide a brief description of the changes to your valid permit by answering the appropriate questions for these changes below. Please submit
completed pages 1-9 of this application form to our Regional Office (see attached list) covering the location of your proposed activity.
A.

Change in covered species:
1.

Identify the 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).

2.

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

3.

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

4.

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

5.

Identify any species to be deleted from your valid permit and the reason(s) for the deletion.

Page(s) & source document:
B.

C.

________________________________________________________________________________

Change in covered activities and/or conservation activities:
1.

Identify any new activities to be added to your valid permit.

2.

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.

3.

Provide a complete description, including timeframes, for implementation of proposed changes to voluntary conservation
activities to enhance, restore, or maintain habitat benefiting federally listed, proposed or candidate species, or other species likely
to become candidates.

4.

Identify any activities to be deleted from your valid permit and the reason(s) for the deletion.

Change in location of the proposed activity:
1.

Provide the original location of the permit, including 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).

2.

Describe any change, expansion, or contraction in the location of the renewed or amended permit or location of the proposed
activity site(s).
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Provide the total number of acres to be covered by the new Agreement
Is this the total acreage of the parcel? (check one)

☐ No

4.

Provide the approximate number of acres to beimpacted

_________________________

5.

Provide the approximate number of acres to be protected

_________________________

Page(s) & source document:
D.

☐ Yes

_________________________

________________________________________________________________________________

Additional changes or revisions:
1.

Describe any additional proposed changes or revisions to your valid permit.

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Enhancement of Survival Permit Application: Option III. Renewal/Re-issue of an Existing Valid Enhancement of Survival 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
or re-issue.
Sign the following statement if you are applying to renew or re-issue an existing valid Enhancement of Survival permit without changes. If you are
proposing changes to your Enhancement of Survival permit, you must use Option 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
Enhancement of Survival permit #

are still current and correct and hereby request (please check

either Grenewal or Gre-issuance) of that permit without changes.

______________________________________________
signature (in blue ink)
______________________________________________
please print name legibly

___________________________
date

* Please note: If you have signed the above statement, then your renewal/re-issue 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/reissuance 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.

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Enhancement of Survival Permit Application: Option IV. Permit Transfer, Partial Permit Transfer, or Succession of a Permit
Complete the following if you are applying for transfer or partial transfer of an existing valid Enhancement of Survival permit to you or obtaining
rights of succession of an existing valid Enhancement of Survival 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 at http://www.fws.gov/offices/
Please indicate the name of the Safe Harbor Agreement or Candidate Conservation Agreement with Assurances to be transferred or succeeded,
and the document’s date.
Name of Safe Harbor Agreement _________________________________________________
Date _________________________
Name of Candidate Conservation Agreement with Assurances _________________________________________________
Date _________________________
What type of transfer are you requesting?
☐ Full permit transfer or succession of a permit
OR
☐ Partial permit transfer
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 Safe Harbor Agreement or Candidate Conservation Agreement
with Assurances.

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ENHANCEMENT OF SURVIVAL 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 Enhancement of Survival permit pursuant to Section 10(a)(1)(A) 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 Safe Harbor Agreement
and/or Candidate Conservation Agreement with Assurances covered by the Enhancement of Survival permit. Further, upon receipt of
the Enhancement of Survival permit, I/we agree to conduct the activities as specified in the Safe Harbor Agreement and/or Candidate
Conservation Agreement with Assurances according to the terms and conditions of the Enhancement of Survival permit and its
supporting documents.

______________________________________________
signature (in blue ink)

______________
date

______________________________________________
please print name legibly
______________________________________________
Signature (in blue ink)

______________
date

______________________________________________
Please print name legibly

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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 1 of the application or, if applicable, on the attached address list.

•

Keep a copy of your completed application.

•

Please plan ahead. Allow at least 60 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
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FWS Form 3-200-54 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1018-0094
Expires ##/##/20##

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.

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FWS Form 3-200-54 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1018-0094
Expires ##/##/20##

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 Marine Mammal
Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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 which affect protected
species. This helps FWS monitor and report on protected species and assesses 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the U.S. Fish and Wildlife Service 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. 1018-0094.
ESTIMATED BURDEN STATEMENT
Public reporting for this collection of information is estimated to average 3 hours 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: PRB (JAO/3W), Falls Church, VA 22041-3803, or via
email at [email protected]. Please do not mail your completed form to this address.
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 nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.23 and 43 CFR 2.24].

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